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And again, thank you very much for joining us. All right. All right, great. I'll get the intro completed here and we'll go from there. Okay. I think so. Okay. Yeah, I see that. I see this. Okay. All right. Great. So thanks. Thanks to everyone who's helping with this session today, our faculty, and then also thanks to everyone participating and being here tonight in the evening. So this is going to be evaluation and management of swimmer shoulder. So the objectives here are to understand how to complete a pertinent history and physical exam assessment, understand swimming biomechanics, the pathophysiology of swimmer shoulder, and the management and rehabilitation of this circumstance. And so this is me, Ryan Nussbaum. I'm a physician at University of Pittsburgh Medical Center. And I'm a team physician for Duquesne University, where we have a swimming program. Next, we have Dr. Shelby Johnson. And so she is an assistant professor at the University of Pittsburgh Medical Center. And she's going to be talking to us about how to complete a swim exam assessment. And so this is me, Ryan Nussbaum. I'm a physician at University of Pittsburgh Medical Center. And I'm a team physician for Duquesne University, where we have a swimming program. Next, we have Dr. Shelby Johnson. And so she is an assistant professor at Mayo Clinic in Minneapolis. She is board certified in PM&R with an added certificate of qualification in sports medicine. Next, we have Dr. Shelby Johnson. She is an assistant professor at Duquesne University. And she completed a residency and fellowship in sports medicine at Mayo Clinic, Rochester. She is a physician for USA Swimming and USA Hockey and is a team physician for a local D3 college. Her current areas of interest in sports medicine include endurance athletes, exertional leg pain, diagnostic and procedural ultrasound, and orthobiologics. There's definitely a theme here. We typically have some sort of affiliation with USA Swimming. So we're pretty excited that they've committed to this session tonight. And so next is Dr. Brian Krabeck. He is a board certified sports medicine physician within the University of Washington Medicine and is a clinical professor of rehabilitation medicine, orthopedics, and sports medicine at the University of Washington School of Medicine and Seattle Children's Hospital. His expertise encompassing comprehensive spectrum of sports-related injury prevention, treatment, and sports performance enhancement. He is the team physician for University of Washington Husky Athletics and is national team physician with USA Swimming. He has made many contributions to the field as a team physician at multiple World Aquatic Championships and also Olympic Games in Salt Lake, Athens, and Vancouver. And he has had a couple of really unique roles as medical director and physician for Racing the Planet for Desert Series Ultramarathons and has been a team physician for Johns Hopkins University and the Baltimore Orioles. And so also serving as concussion management physician for the XFL Seattle Dragons. And he's got great clinical expertise for advanced medical procedures, ultrasound guided techniques, platelet-rich plasma applications, and 10X as well as fluoroscopic lumbar spine procedures. Dr. Adam Lovenow is the next speaker here. So he's an assistant professor of PM&R at the Department of Physical Medicine Rehab Department at the University of Michigan. He earned his undergrad at Northwestern University, and he was also on the swimming team there, the varsity swimming team. You were both there at the same time, is that right? Kind of? I'm all overlapped. Overlapped a year. Overlapped, okay. Well, that's pretty cool. A little bit, yep. Okay, and so Dr. Lovenow did his medical school at West Virginia School of Osteopathic Medicine, and then he did his residency at the University of Pittsburgh Medical Center. And then he went to University of Michigan for a fellowship, sports fellowship, and he is a team physician for both University of Michigan and Eastern Michigan University. Yeah, he wears a lot of hats covering a lot of different teams up there and has previous experience with both of covering those universities. And more recently, Dr. Lovenow, Eastern Michigan, right? That's more the... Yes, Eastern Michigan and then consulting for Michigan. Nice. And then also a team physician for USA Swimming. And there's a common theme here, these focuses of interest. He looks at really anything, joints, tendons, nerves, and looks at endurance athletes, performing artists, and high-level musculoskeletal ultrasound. And then Dr. Matt Sherrier is our final speaker. And so he is an assistant professor at the Department of Orthopedics and Physical Medicine and Rehab at Medical University of South Carolina. He completed his undergraduate studies at College of Charleston and was a Division I swimmer there. And he completed medical school at MUSC and was... Jeez, you're a coach at the same time. That's okay. Busy swimming coach at College of Charleston at that time and completed his PMR residency at UPMC and fellowship at Northwestern Shirley Ryan Ability Lab. And he is currently the co-director of MUSC Brachial Plexus and Peripheral Nerve Clinic, Injury Clinic, and serves as team physician for South Carolina Stingrays Professional Hockey Team and USA Soccer Federation's Extended National Teams. So really, really great group. They're definitely passionate on this topic. And I think, you know, having them on here, I know personally, this has been a challenge for me, right? I think swimmer shoulder is difficult. So I try to put together a theoretical case that we would then go into all the discussions on and all the topics. But this is someone that maybe a little to the extremes, but a junior collegiate swimmer in our training room, right shoulder pain, pain with all swimming sessions, consistently having pain with daily living, strength and conditioning. The exams are a lot of them are positive. And then, of course, maybe you get an MRI, it shows supraspinatus, subscapularis, teninopathy, and a questionable labral tear. And I think it can be somewhat of an intimidating circumstance to work through. And that's why we brought all these experts here to help us out. So I think, Matt, you're first, right? Yeah, I think that's right. I'll see if I can share it here. Give me one second. Okay. All right. Cool. Can you see these slides? Just go away again. Matt, Matt, do you mind if I share something real quick? Yeah, yeah, no problem. I got I got too excited to jump into this. Sorry about that, everybody. You got it. So this whole session is about trying to sort out how do we effectively treat someone like this. And this is how it's broken down. So Dr. Sherry is going to review epidemiology of swimming shoulders. Biomechanics, kinetic chain of swimming will be Dr. Krabeck. Eval, an exam of the swimmer, will be Dr. Johnson. And then rehab, return to swim is Dr. Lovenow. And then we'll open it up to a panel. I think if anyone has any questions, in the meantime, you can certainly raise your hands. I think try to keep this somewhat informal. So, yeah, all right, I'll shut up. All right. Let's see if this works here. All right. You guys able to see these slides here? All right. Cool. All right. Well, thanks for the introduction. I appreciate it. So we're going to talk about kind of an introduction to the sport of swimming. And then we'll touch on what's known about the epidemiology of swimming injuries. These are my disclosures. This is for research unrelated to this presentation that's provided directly to my institution. So we'll talk about some overview of the sport of swimming. Talk about some lingo related to swimming. We'll touch on some aspects of training for competitive swimming. And then, like I said, what we know about the epidemiology of swimming injuries at this time. So swimming, it's a very popular sport in the United States. You know, both recreationally and competitively, with USA Swimming being the major governing body of it in America. You know, they have, as of last year, about 400,000 members, just under 3,000 club teams. Roughly more or slightly more females than males. You know, young children typically start swimming competitively around the age of six years old. And so what we see is that the largest age group of USA Swimming members is the eight and unders. There's a common theme you see with USA Swimming membership is that there's typically a spike after Olympic years. So, you know, 2009, 2013, 17. There's a pretty significant dip kind of around the COVID years, and it's somewhat recovered since then. High school swimming participation is actually a little difficult to assess, but it's probably in the ballpark of about 300,000 athletes per year. And again, slightly more females than males with that. Now, competitive swimming consists of four primary strokes. So you have the freestyle, which is this alternating overhead movements and a continuous flutter kick. There's a couple of components to it. You have the arm entry and extension. You have the catch, the pull phase of the arm coming through to the hip, and then recovery as it comes out of the water. Backstroke is performed on the back, looking up at the ceiling with alternating movements and a continuous flutter kick as well. And then butterfly, you have simultaneous overhead movements and this undulating body motion with what we call a dolphin kick, where the legs perform a simultaneous kick originating from the hips and kind of terminating with rapid plantar flexion at the feet and ankle. And then breaststroke features this unique frog-like kick and this simultaneous kind of in-sweep and out-sweep of the arms to help propel the athlete forward. So these are the four strokes. There's also individual medley, which is a combination of the strokes going from butterfly to backstroke to breaststroke to freestyle. There we go. However, you know, regardless of the athlete's stroke specialty, the training is primarily done in freestyle. So this is a study out of elite athletes from Australia, where just over 50% of the training is done in the freestyle stroke. This mimics my experience as an athlete and a coach as well. The events can range, you know, in freestyle anywhere from the 50 freestyle all the way up to either the 1500 or the 1650, depending on the metric that you're swimming. You have the hundreds and the 200s of the different strokes. And then from an individual medley standpoint, 200 and 400 yard I am. These time ranges represent those of high school swimmers. And so you can see there's a lot of variability just depending on their ability level and their competitiveness. And what you'll also notice here is that these are yard freestyles. So this is yards demonstrated, which is the most common way it's swum in the United States. However, obviously, internationally, it's swum in meters. And there's different pools that the events are competed in. So you have long course meters, which is this large rectangle here. This is what you'll see if you're watching the Olympics. This is the type of pool the athletes are swimming in. Short course meters is in the bottom left hand corner, you know, half of that 50 meter pool. I'd say it's a lot less common, particularly in the United States, but you'll see it in certain international competitions and world championships. Short course yards in the upper right hand corner is by far the most common in the United States. You know, for high school swimming, for the NCAA level, that's usually what they swim. And then not to neglect open water. So open water races are, you know, in lakes, you know, rivers, oceans, things like that. And the distances often exceed pool events, typically in the ballpark of a 5K or a 10K or things along those lines. Now there's a progression through the sport that you'll see swimmers go through, and they don't always follow this linearly. But I'd say most common, at least where I live, the first introduction to swimming is in summer league swimming. So, you know, very short season, a lot of racing, a lot of candy, a lot of fun. This is my daughter's summer league swim team here. And then depending on how that goes, if they express interest, they'll move on to the club swimming level, which is, you know, typically year round training. And there's opportunities for higher level competitions with that. High school swimming, you know, in high school, kind of a shorter season. And what you'll see is that the more competitive high school swimmers are typically swimming with a club team concurrently as well. Very few kind of go on to the NCAA level, and then even fewer than that go on to the professional level. And you see there's an overlap of the highest level NCAA swimmers going on to be professional swimmers typically. But regardless of the, you know, the level of competition, the training and practice structure is the same. So you have a warm up, you have a main set that, you know, really depends on the session's goals, but it's focused on, you know, speed, endurance or technique, and then kind of a short cool down after that. There's a number of tools that are used in swimming that I think are important to kind of be aware of. So hopefully you can see my clicker here, but this is a kickboard here on the left hand of the screen, typically used with the arms kind of extended overhead, you know, focusing on your kicking strength, kicking endurance and technique. These are fins or flippers, you know, to increase the surface area on the foot, help propel yourself faster. These are paddles, which go over the arm, help to increase the surface area of the hand and help kind of develop upper extremity strength and power. Often coupled with what's called a pull buoy. So that's this device you're seeing here, a little foam pull buoy, where your thighs kind of rest in these little grooves in between it, really to help focus on your pull and help to keep your legs kind of more towards the surface of the water as you're doing that pull. And then you have your snorkel here just to eliminate any head movement during breathing, which can be useful for certain drills. And then other tools that you'll see kind of in higher level club and at the college level as well are things like parachutes, with a parachute being dragged behind the athlete, you know, attached to them with kind of a waistband. These pull cords or these bungee cords, which can be used in two ways, either to apply increasing resistance as you swim further away from the bungee cord, or to go to the extent of it and get kind of pulled backwards, you know, allowing that bungee cord, pull cord, typically with assistance of one of your teammates to help you kind of, you know, optimize body position when you're at top speed. And this is what's called a power tower. So it's, you know, these buckets that are filled with variable amounts of water to apply, you know, variable amounts of resistance attached to this pulley system and then to the athlete's waist with this waistband here, typically for very kind of short duration power sessions that you'll see. Now, just like many sports, periodization or, you know, planning your training is a big deal in swimming. And so it's divided into different aspects. So you have macro cycles, which, you know, at the level that I was at was typically broken into seasons. But in the higher levels, they'll break this even into quads or kind of over the course of four years as you're training for Olympic Games or World Championships. Mesocycles represented down here in terms of months and then micro cycles are what you're kind of doing on a week to week basis. And then with swimming, you know, tapering is a big deal. So it's this, you know, this concept of, you know, reducing your training volume while you maintain intensity to try to optimize your physiological and psychological performance. And so anyone that's been involved in swimming, either on a coaching level or an athlete level, knows that this is really just as much of an art as it is a science to try to get yourself or your swimmer swimming fast on the day you want them to swim fast. Now, for many competitive athletes, swimming is an all year sport and there's very little rest time. You know, many swimmers will engage in two day practices or doubles beginning at the age of 10 or 12. You know, by the age of 11 to 14, you're doing about five sessions per week, covering roughly 5,000 to 7,000 yards or meters per session. Anywhere from, you know, an hour and a half to two hour sessions and weekly yards kind of approaching 25,000 to 40,000 per week. And when you get kind of to the high school level, you're typically seeing more sessions, often adding some strength training sessions, about two hours per session as well. And the weekly yardage is really going to vary depending on a couple of things. Probably most importantly is the coach's philosophy when it comes to training, but also whether you're a sprinter or distance swimmer, they're going to have different physiologic demands of their events. There's been a couple of studies on this, you know, the amount of volume that swimmers do. And so this here on the left side is, you know, high school age club swimmers in North Carolina, where most of them are swimming about 6,000 to 7,000 yards per practice, but, you know, ranging anywhere from 5,000 up to 9,000. The right two figures over here from elite Australian swimmers. And so they're swimming in the pool, you know, on average 16 hours per week, but there's, you know, some variability there. And the number of kilometers per week they're swimming on average is 40. And this mimics my experience as well. And so the estimates that we have from the literature are, you know, anywhere from 40,000 to 75,000 yards or meters per week. So that accounts for about 22 to 40 miles per week of swimming. And this is done for, you know, most of the year, 11 to 12 months. So quite a lot of volume. And if you break that down even more in that, you know, if you think about these sessions, not just in terms of yard, but in terms of the number of cycles or arm strokes that these athletes are getting, you know, there's estimates of 30,000 strokes per arm per week and estimates that the average collegiate swimmer performs more than a million strokes per arm per year. And so these are, you know, very high volumes. But I think this gives us, you know, a general idea of the repetitive motions that swimmers perform. And it really underscores the importance of monitoring their training loads to try to prevent overuse injuries. And, you know, during the training sessions, a significant demand is placed on the shoulder, with estimates of about 90 percent of the propulsive force from freestyle, you know, being generated from the upper extremity, in particular the shoulder. And so that can predispose the shoulder to, you know, injury with training. And so this is, it's commonly referred to as swimmer shoulder, which is, you know, a very broader kind of general term that encompasses several potential etiologies, anywhere from hyperlaxity, multidirectional instability, scapular dyskinesis, subacomial impingement, labral damage, presence of an osteochromia alle, super scapular nerve entrapment, or Lunninghamer rotation imbalances. But what I also find interesting is, you know, the swimmer's actual attitudes, you know, the athlete's attitudes towards shoulder pain. This is that study out of the, you know, high level club swimmers in North Carolina from a few clubs there. And, you know, 95 percent of these swimmers believe that mild shoulder pain is normal and it should be tolerated. You had 85 percent reporting mild shoulder pain in the last 12 months, and 61 percent reporting moderate shoulder pain in the last 12 months. But what I find interesting is that, you know, of these athletes, only 14 percent reported an injury to a team or medical staff. You know, additionally, those that are reporting shoulder pain, 72 percent of those report using pain medications in order to participate in their practice. And of those who use pain medications, about half of them are using them regularly, which is quantified as one or more times per week just to get through practice. And so I think it's important to know, you know, as a physician that, you know, swimmers might not associate shoulder pain with an injury. And so they might not actually seek care and they may just choose to kind of self-medicate. But this can also make, you know, assessing epidemiology somewhat challenging because there's a very low reported rate of injuries in swimmers that we'll touch on. But this is probably more so indicative of the swimming culture, more so than the actual true incidence of injury in these athletes. So this is the most updated systematic review from a couple of years ago. And so, you know, swimming, it's a sport of a relatively low risk of injury, I'll say that. But the previous studies have used varying methods to report swimming injuries. So it leads to these disparate reporting rates and somewhat difficult to assess. But, you know, sometimes they're, you know, interpreted of, you know, the number of injuries per 1,000 hours of exposure, injuries per 1,000 athlete exposures, like to an athletic trainer, or, you know, at certain events, which is what this last one is from, you know, the number of swimmers per 100 registered athletes that are reporting injuries. But a common theme is that, you know, the shoulder is the body part that's most affected by injuries, anywhere from 16 to 76 percent, which is, you know, a very wide range, with risk factors including repetitive cyclic movement of the glenohumeral joint in a positive correlation with training time and training distance. This study showed that butterfly and backstroke had higher prevalence of injuries. The severity of injuries, you know, in terms of measured by the duration of time needed for recovery are predominantly short-term and in ballpark of less than seven days. It's because injuries such as fractures or high-grade ligamentous or tendon tears, which requires, you know, surgery sometimes or long recovery periods, are pretty rare in swimming. So this is the most recent high school data that we have from an athletic training online reporting system over a course of about 11 years. It reported a very low rate of 0.26 injuries per 1,000 athlete exposures. Most of the injuries were to the shoulder, about half of them, associated with freestyle and classified as overused or chronic. And then, you know, females had slightly greater rates of injury overall than males, as represented here. There's a couple of studies from the NCAA, you know, from 2009 to 2014, injury rates of 1.54 per 1,000 athlete exposures, with female swimmers having a higher overuse injury rate, but no gender differences in terms of overall injury rates for that period of time. An updated study was done a couple of years ago showed very similar injury rates compared with the previous study. Again, largely, most of them were attributed to the shoulder and attributed to overuse mechanisms as well. This is a study I found interesting at the University of Iowa. It's obviously a single institution over the course of about five years, reported much higher injury rates for males and for females on that team. They found that freshmen swimmers seemed to suffer the most injuries, and there's a significant pattern of fewer injuries in later years of eligibility. I think there's a couple explanations for this. Number one is that those who have either coached or competed at the college level know that that transition from high school to collegiate swimming requires a significant increase in volume, typically, and a lot more strength training that's done. A second explanation, at least for this last point here, could be a survivorship bias and that the fewer injuries after the freshman season could be that those freshmen swimmers just decided no longer to swim after that period of time. But not to be overlooked, the shoulder dominates the literature when it comes to epidemiology, but knee injuries are the second most injured body region and, again, are mainly caused by overuse. Breaststrokers, in particular, up to 75% of them report medial knee pain at some point throughout their career, likely secondary to a large valgus moment that happens with that breaststroke kick, which can put a lot of stress on the MCL. You can get anterior ankle tendon injuries and posterior ankle impingement that may occur from the flutter kick or dolphin kick because you're in, you know, plantar flexion of the ankle for prolonged periods of time. Then injuries I've seen many times, you know, the fractures and injuries of the foot and ankle from hitting the wall during flip turns. And then the lumbar spine as well with a higher prevalence in butterfliers, which consists of 33 to 50% of lower back injuries. So in conclusion, the preparation for competitive swimming involves a high training volume and exertion. This, coupled with the repetitive nature of swimming, are risk factors for overuse injuries. The methodological variability makes epidemiology challenging to assess, but common themes occur in that the shoulder is the most commonly injured body part and is most often associated with overuse. These are the references I used. And with that, I'd like to thank you all very much for your attention. I think I'll hand it over to Brian here. Awesome. Well, great set up there. Hopefully, let's see. We're going to share my presentation, hopefully. Everyone can see that. Give me a thumbs up. Good. There. All right. Yeah. So, so, right. We have a good understanding of, of what swimming is. We have a good understanding of the type of injuries of which shoulder is the main thing. We have a good understanding of, of what swimming is. We have a good understanding of the type of injuries of which shoulder is the main thing. My focus is going to incorporate the sort of the kinetic chain because we're physiatrists and we think of the functional aspect of, of all of this. And we're going to, we're going to utilize our knowledge of that to go ahead and take a look at the swimmer because understanding the basics of, of what swimming is and taking a little bit deeper dive, no pun intended into this will be a nice setup for figuring out how to evaluate these athletes and how we can rehabilitate these athletes. And I've been fortunate. I've been traveling with the U S swim team since way 2009. And apparently I couldn't give it up after Paris because I'm heading again this summer to world. So I had an opportunity to work with a varieties athlete and there's a pretty common theme, you know, understanding the mechanics and the motion are an important component of this. And as we provide care, we still have to incorporate our understanding of this. So, you know, and swimmers are unique. They have different bodies. They have different specific gifts in regards to how they're designed. A lot of them are pretty hyper-mobile or have a lot of laxity as we can appreciate into these two pictures of Phelps and Gretchen Wall stood there. But more importantly, as we think about things, we got to step back and think about something that's very unique to swimming, right? And it's the fact that we're in water, water is 800 times denser than air. And there's principles around how we float in water and how we're balanced in water that impact our ability for risk of injury. And so I like this diagram here because it's an important thing. Archimedes principle is about how we displace water when we get into it. And we all have a center of mass, how we're defined based on how our architecture is that has a component for which we're going to have a center as we're moving through the water. And that has to adapt and play in concert with the fact that we have a buoyancy force, right? The buoyancy, the force of the water pushing on us or weight going down and how that center is for each of us is very different within that aspect of it. And it becomes important because our center of mass and our center of buoyancy are not necessarily aligned, right? So if you have a big, long torso and your center of mass is towards the back, or if you're like me with really dense legs, my legs are going to float down. And how I breathe and incorporate that center of buoyancy factors into whether I'm going to be streamlined, like on the top, or whether I'm going to be less streamlined and incorporate more drag or resistance into how I move through the water. And swimmers spend all their time trying to be as streamlined as possible so they can move through the water as quickly as possible. And I was an engineer and undergrad, so I like to think of this in regards to this video that comes up, right? And then this brings into the basic construct of in order to move through the water, we have to stay in motion. And for swimmers, there's a constant battle between this propulsive force where they're trying to move through the water and this resistance or frontal force or drag that's trying to slow them down. And to maintain your speed, there's a constant battle between these two forces. So swimmer work on being streamlined, developing the technique to move the propulsive force while minimizing drag throughout. And we know with Newton's third law, for every action there's an equal and opposite reaction. So our goal is to push the water, to interact with the water, to grasp the water and move through it. And the hydrodynamics of that water moving through impacts how we move. And if you really think about it, swimming's unique, right? In baseball, we talk about the kinetic chain and how that force comes through the lower extremity and puts through a ball to propel it. Where in swimming, we're balancing in some essence, some open kinetic chain types of movements when we get off the block. But then in the water, we're interacting in a surface that's moving. It's almost like it's a closed kinetic chain type of movement with a movable force as well. And so we have to think about this dual action movement as we're going through the water and the forces that go there. And our swimmers spend a lot of time looking through all this and the nuances of it all. From your fingertips to your toes, there's all these different forces that are interacted with workflow and drag. And swimmers are adjusting this continually throughout to try and figure that out. So when we think about swimming, most of us want to deep dive into the biomechanics, into the stroke. Let's see what's going on. But we're going to take it a little different view of this. And we're going to use a lens of from the start to getting into the water, to doing the stroke and pushing off the wall. So there's always a start. And then as the person dives in the water, they have their underwater, which is how they're propelling themselves underwater as quickly as possible. So that breakout where they're piercing the surface of the water to then do their stroke. And then you get to a wall and have to do a flip turn and go back and forth, depending upon the extent of what they're swimming with this, right? So let's start with the start here. So here's a nice study that looked at the kinematics at the start. And what you notice here is like for most part, everything starts on the block, unless it's a backstroke where they'll be in the water holding onto the block itself. But the principle is that is you're getting into this, this very compact component based on your sort of center mass to be balanced on the block itself. And then you have to activate all your muscles and kind of a kinetic chain to, to push yourself all the block and optimize the angle for what you're going into the water and at the right attitude to enter appropriately. And as I mentioned, water's 800 times denser than, than air. So coming in at the wrong angle, having looseness, as was mentioned earlier, hypermobility in the shoulder could lead to subsequent shoulder injury to this. And if you don't optimize how you're moving in the water, that becomes important. And if you think of it as a kinetic chain component, right? The, we think about how there's this contraction of all these muscles on the block to store that potential energy. And you can see that when they start, cause they get really tense. And then you have to activate in a dual kind of system, activating the glutes to the quads, the calves, the ankles, feet, and toes to leave the block while at the same time, bringing your arms forward in a kinetic chain, scapular to the shoulder, elbow, wrist, hand to enter the water itself. And this sequence of events must happen in a very quick period of time to optimize how you're moving. And so let's, let's take a look at this a little bit more in some videos. And as I remembered, like the first thing is sometimes you don't have the right optimal angle here. So go out too far, go out too much. And it's called the belly flop. And then you're going to hit the water and get injured, go too vertical. And you're going to be in essence, competing and diving in regards to how you enter the water there. So that's my ninth attempt at humor with that. But what we really want to look at is, is here, here's a great video. And this is Caleb Dressel, great start. And we're going to watch the video once. And what we're going to notice really is how he starts and how he has to use his kinetic chain and take an advantage of, of how he has mobility and strength in his shoulder region, as well as hips to enter the water. So when we look at this and we'll slow it down a little bit here, first, what you can appreciate is they're at the start. They say on your mark, they get going, and then you can see how they can compress. He's pushing down as well. And as he's pushing off, watch that shoulder movement. And one real unique thing about Caleb was just how he would put his arms up high to give him momentum. And if you look to the right on the guy from Cal and look at the difference about how the activation of the kinetic chain and pushing those toes off the start and the angle through which his arms in and quick streamline is very different than the guy in the Cal next to him, who just really is not getting that motion and movement through there and is not as efficient off the block itself. And then looking at that angle into the water. And so the swimmer spent a lot of time trying to optimize this. And as you can imagine doing this over and over again can lead to subsequent injury, such as the shoulder itself. All right. So now we entered the water and we're underwater and going to our breakouts. And this is where you'll see a lot of times people are doing the dolphin case undulation underwater. I like this article here because it highlights some of the key things in regards to the underwater position and the dolphin kick, which is typically used in every stroke in some capacity here. And what we have here is a diagram of the athlete as they're going through. What I like is in this graph, and I'm a visual kind of person, is you can see how there's a lot of movement in the lower extremity in regards to the knees itself and the angulation of the hip and the ankles, where there's more streamlined and stability in regards to the shoulder joint and the torso itself, which is the lines in the middle through here. Again, this requires significant strength and energy as you're going underwater to move as quickly as possible. And if there's any disruption in this movement, you can get subsequent injury, which is what we're trying to prevent. And one of the best people we can see for an underwater here in the center is Gretchen Walsh. And I want you to take a look at a moment at her in the center as she's moving through, and you can kind of appreciate how she can maintain that streamlined position with her upper body with minimal movement while utilizing the forces of her hips and her knees and her ankles to go through. And if you compare that with the person to her right and look at just the extent to which someone's undulating, and the upper body movement here where she's definitely not as streamlined, you could imagine how incorrect motion and movement could lead to stress to the shoulder itself, to the spine itself, and subsequent type of injury. So we have to think about how the athletes are incorporating all of that into their training program. And then we finally get to the biomechanics of this, and this is where, as was highlighted earlier by Matt, there's different strokes, freestyle, backstroke, breaststroke, and butterfly. The vast majority of time we're spending time in the freestyle, and there's phases like everything. You've learned about the kinetic chain and the phases of movement and activation for throwing a baseball, same thing in swimming. And each stroke can be broken down into various different phases. Here what I like is a nice summary of the phases that we go through where there's entry and catch, where they start to pull forward, push through to get that energy, right, for every action equal opposite reaction as we saw that, and then a recovery phase. And as we move through the different stranges of the stroke, there's a change in the overall position for how the shoulder goes from abduction, flexion, internal rotation, through adduction, external rotation, and then full recovery. And limitation in motion and movement can play a role in regards to how that can lead to subsequent injury. And I like this chart because it highlights some of the muscle activation patterns that you see when some of the different muscles around the scapula and the shoulder itself are activated to allow us to progress forward. And as you'll see a common theme, right, when somebody does this correctly, you can see a nice entry catching the water and going through with good rotation, right, this person's really working to move the water. But when you get someone who winds up getting injured or has the potential to get injured, you start seeing errors. So this person on the rest, on your right, you could see how they're basically crossing over their body. They're not rotating as well. Arm's just not in a great position as the person on the right. And this can lead to subsequent injury. When Dr. Johnson comes, speaks later, she'll talk a little bit more about the importance of figuring out some of these techniques as well. In a similar fashion, here's the backstroke. It can be broken into different phases. I'm not going to go through every stroke. But in a similar fashion, as an entry catch, there's a pull push component to all of this. The shoulders going through its range of motions and activating different muscle groups throughout. And it's important to understand that. So when you go through the evaluation, the rehabilitation of these individuals, you're going to ask about when during the phases they're going when they might be hurt. And in a similar fashion, you could look at different errors. Here's again, here's a nice backstroke where the rotation's good. They're grabbing the water. You can see the other person over here looks flat, their arms too much out to the side. And getting some of the videos can be very helpful in figuring this out. And I like this slide. It's a nice summary here where it shows the activation of the different muscle groups throughout each of these biomechanical movements itself. The top two, freestyle and backstroke, are often referred to as long axis type of maneuvers because you're rotating along the long axis of the body. It takes a lot of engagement of core throughout. The bottom two, the breaststroke and the butterfly are more short action type of strokes, where there's an up and down movement to it. And you can imagine through the various different undulations that can lead to pressure in the shoulder, especially like in butterfly, as opposed to the back or knee in breaststroke or the back in butterfly as well. As well. And then we finally get to the wall. We're kind of flipping through here. So we're working ourselves through this kinetic chain, activating all of this. And in a similar fashion, you're going as fast as you can into the wall and you have to turn, flip throughout. And it's a reactivation of that kinetic chain, sort of similar to like a squat jump, except now you're doing it off the wall itself. And sometimes you have to do it just once and sometimes you have to do it multiple times. But there's this, again, energy transfer as we're storing that energy, placing our feet on the wall and then pushing off and doing our next underwater breakout as well. And, you know, can't get a legend like Katie Ledecky here going through, got to incorporate her. And you could see how she's really swimming into the wall and is timing it perfectly to land at the proper position to go through her turn, rotation, activating all those muscles at a specific distance below the wall before she pushes off and goes through. And as mentioned in regards to load and swimming, this happens, you know, hundreds of times throughout. And that leaves us with our final little thought as we're going to transition to evaluation and rehabilitation is, what are the risk factors that get us into trouble? And I refer to the study by McKenzie in 2023, it was a systematic review looking at shoulder injury. And they use some strict criteria in trying to figure out the various risk factors, extrinsic and intrinsic, that are associated with the potential risk for injury or weren't necessarily. And they pooled a whole bunch of data and utilized some strict criteria. And what I find interesting through this is, there's some things not modifiable, but if we could prevent injury, right, as opposed to having a history of injury, that's an important thing to ask about. Because if you have a history of injury, you're anywhere from four to 11 times more likely to get subsequent shoulder injury as well. There's some modifiable risk factors relating to like technique, right, the competition level, as referred to earlier. Workload is an interesting discussion we can have later in regards to how that will impact the risk for injury, whereas other factors necessarily didn't. And then if you look at some of the things that we deal with when we're evaluating people, this is a nice summary, really can point towards things in relation to dynamic movement and fatigue and strength in regards to putting the shoulder at risk, as opposed to some of the static things we measure, which are important to realize, but may not be as associated with subsequent injury. And we can discuss this more later in regards to the Q&A itself. So in summary, hopefully as you're moving forward, we know the type of injuries people get. I want you to take a deeper dive into understanding the various phases of swimming, how the kinetic chain plays a role, and this aspect of how it moves across the body on a movable surface itself, and how developing dysfunction can lead to subsequent injuries. And an individual evaluation and treatment program will focus on these key areas while understanding the biomechanics that can then allow us to keep those athletes healthy and can optimize performance as well. And I'll stop there and hand it over to Dr. Johnson, who can tell us how to incorporate all this knowledge from these first two lectures to evaluating these athletes. Great. Thank you. Thanks, Brian. So, first off, I apologize I'm red. I'm not sure why I am. But anyway, we'll talk about the evaluation of swimmer's shoulder. So the evaluation of these athletes is really going to be very similar to your evaluation of any athlete that comes, especially our overhead athletes. So you'll want a good history, physical exam. You potentially may want imaging. However, I feel like in most cases, you don't really need any imaging. With these individuals, with this sport especially, it's really nice to have at least videos of their stroke, and that can be home videos. It doesn't have to be anything professional, but we'll go through a little bit of that as well. But first, in talking with swimmers, some of the terminology that Matt used earlier is really helpful to kind of gain the trust of these athletes. I feel like as a swimmer myself, not many physicians knew the sport of swimming, and so if you can at least connect with the athlete and know some terminology, I think it's really helpful for these athletes to really buy into what you're saying. Specifically with history, so you're going to ask your typical questions, onset, quality, irradiation, what makes it better, what makes it worse, et cetera. But with swimming athletes, especially our younger athletes, you're going to want to know about any recent growth. Have they had big growth sports recently? Are they on a new team with maybe a different coach, with maybe a different perspective for their coaching strategy, or are they on a new level? So did they graduate from 11, 12 age group, and now they're more with a senior age group, and that may mean more hours in the pool. It may also mean higher training volume. At what point during the stroke does it bother them? So is it, as Matt and Brian talked about, is it during the catch part of the stroke or is it more during the recovery part of the stroke? What time are they in the season? Is it the start of the season? Is it middle of the season? Or is it taper time and they've got to have a big event coming up soon? Also really good to know if they're in short or long course. So long courses, Dr. Sherry mentioned earlier, is going to be over double, typically, at least in the United States, what they're doing for short course. Ask them what their primary stroke is or distance. Again, these athletes are going to be doing primarily freestyle, but if they're freestyle specialists, they're going to be doing pretty much all freestyle during practice. You want to know their practice hours per week. Are they taking any time off? And have they had any previous injuries, whether that's the lower extremity or upper extremity? I will say like a lot of our younger athletes, swimmers are often very bad historians. So one, if you can connect with them, but also if you can use their parents or even like coaches for a little bit of help with it, that can be very helpful as well. So physical exam is going to be really similar to the physical exam you'll give for any overhead athlete. So you'll start with inspection. A lot of these athletes have a kind of forward head position, rounded shoulder. So they have increased thoracic kyphosis. They have decreased cervical lordosis. They have these protracted scapulae and their humeral heads are often internally rotated and anteriorly positioned. You'll often see like the restricted anterior shoulder musculature, weak scapular stabilizers. They might have tight monohumeral posterior capsules as well. A lot of these athletes, because of what I mentioned earlier, you may see winging in these athletes and it's probably going to be bilateral if you see that. And then you'll also want to look for any symmetry or atrophy. So with range of motion, just looking at their scapular thoracic motion, do they have any mid arc or end range pain that may suggest impingement or AC joint issues? You'll want to assess their strength. Maybe they have, again, rotator cuff impingement or even rotator cuff pathology. And then special tests. A lot of these will be positive on these individuals, especially because swimmers are just naturally a little bit more, like have multi-directional instability. So they're going to probably have positive sulcus sign. They're probably going to have a loaded shift sign. Their apprehension testing may be positive because of their inherent hypermobility with the sport. I think what's unique to the swimming population is that in an ideal world, and I know it's not possible with every athlete, but you want to take a look at their stroke. And so it's really valuable to be able to watch them swim. So if you have like a treadmill type of pool or a pool in your clinic, you can watch them swim or just have them bring in home videos, just keep in mind safe sport if they're minors. Why we want a stroke analysis is that if their mechanics are flawed, especially if they're doing the amount of repetitions that Dr. Sherry was mentioning earlier, that can result in injury and probably more important to the athlete that results in poor performance. And if a swimmer is coming to you with pain, they likely have bad mechanics. And so there's something that needs to be fixed with their stroke. So I know Dr. Krajewski went into great depth on this, but I'm going to just give you kind of three parts of the stroke to watch. So there's the catch where the hand is in the water grabbing, grabbing the water, the recovery where the hand is going above the water. And I'm talking mostly about freestyle right now. And then the finish where the hand is kind of extending back behind them. You'll also just want to, in general, look at their body and head positioning if you're looking at their, like a swimming video. So with the catch, so ideally, and I hope you guys can see my laser here. So with the catch with freestyle, they really should be creating this kind of triangle with their arm. So their elbows out to the side here, their upper arm is sort of in line with their back. So that's optimal mechanics right there. So they're rotated at about maybe a 30, 35 degree angle here. And then their hands are going to be pointed in and down. If they get too far out and if their hands are pointed out here, that leads to potentially like impingement, rotator cuff issues. The next part of the stroke to watch is the recovery. This is again when the arm is out of the water. So ideally the hand is starting that motion. It shouldn't be the elbow. It should be the arm that's starting that motion. I'm sorry, the hand that's starting that motion. The arm should be swinging wide and to the side. So again, it's creating this triangle with water right here. If they're bringing their elbow too high, like up here, again, that's creating a little bit too much rotation. Your swimmers want to have a good body roll, but too much rotation can put excess load onto the shoulder as well. And then the finish, I don't have a great picture here, but the elbow should be exiting the water first, not the hand. That again can cause issues with the shoulder. In all these videos and pictures I have, they're courtesy of Russell Mark, who's this awesome swimming analysis. And so he does really good video analysis of these swimmers. And so a lot of elite athletes or even younger athletes will have analyses by Russell Mark. But anyway, so this is Connor Dwyer. He's an Olympic gold medalist in the freestyle medley and you can see. So this is push off underwater right here. And then this is his stroke. So he's got a really nice body position. So his hips are kind of up at the top of the water. He's got a good body roll, but he's not over-rotating. And then if I kind of slow it down here, you can see he's got a really great catch with his arm. So it starts here and then he's pulling that water through. Elbow is exiting the water first, and then you can't see the recovery part of the stroke. With him, his head might just be a little bit high. You can see his head here, a little bit higher than the rest of his body. But overall, obviously Olympic athletes are doing a very good stroke mechanic in general. This is Katie Ledecky. So everyone knows Katie Ledecky. She does quite amazing stroke mechanics. And so you can see again, she's got really nice body position. Her hips are at the top of the water. She's got a good head position here. And then if I slow it down a little bit, you can see again with her left arm there, her elbow is bent slightly. Her hand is pointing down and in. And then she's got that great catch with the water. And then again, elbow is exiting the water first there. So a lot of you are probably like, well, I'm not going to have those videos. I don't have an underwater camera. I don't have someone who can bring in videos like that. That's fine. You can get a lot of information actually from videos that parents just take. And so this is just a young recreational athlete and it's showing a video of her breathing. So lifting her head out of the water or not breathing. And so you can get a good sense. She's got a good catch here. Maybe have her hand bring in a little bit more here. Overall, she's got fairly good mechanics. You can see her body position is relatively high. She can't lift her head up in the water too high when she's breathing. But you don't have to have those really fancy videos to be able to take a look at these athletes. So that's on imaging. So I very infrequently will order imaging for these athletes. Maybe get x-rays, maybe do an ultrasound. I'm rarely doing MRI doing CT. So a lot of these athletes is just based on the history and exam and potentially videos too. I just wanted to bring up a couple studies however. So on primarily ultrasound evaluation of these swimmers. So this was a study by Scott, Dr. Rodeo, who's very well known in the swimming community. He's an orthopedic surgeon and he looked at 42 swimmers that were on the 2008 Olympic team. So very elite swimmers. Two-thirds of them had a history of shoulder pain, but this was leading up right to the Olympics. So they were relatively symptomatic at the time. But the majority of them had pathology. So over almost 100% had issues with their rotator cuff. Three-quarters had issues with their biceps. And then impingement was seen in just over three-quarters as well. This has also been shown and reproduced in elite Portuguese swimmers as well as master swimmers. So I just, I bring this up because one, people often think of swimming as the safe joint and body sport. You know, it's a lot of people kind of like, oh, you were so smart to do swimming. Your body, you know, is probably very healthy because of it. Actually does a lot to the shoulder and majority of these swimmers, especially if they're elite, are going to have findings, have abnormal findings. I also bring it up because imaging on it with all of our athletes, but with swimmers, especially if you're going to do imaging on them, you're probably going to find bad things. And so it's really not necessary to do all these imaging tests, especially if they're not symptomatic. And so just keep that in mind, especially if you're going to be ordering any imaging for these athletes. And that's it for evaluation. So I will let him take over. Well, I get to be our fourth of our little relay here. So hopefully I can finish out strong as our anchor. I will be having the chance to talk with you guys about the rehab aspects of the shoulder. Uh, maybe. So the big thing that I would like to kind of get through is there are a lot of different methods and different ways that you can approach the swimmer. And there's going to be a few key concepts that are really kind of important to kind of get through. And that is the idea of what is moving versus what doesn't actually move in the swimmer. We have a learn kind of hyper-mobility and learn motion pattern, but that also means certain areas probably may not be moving the best way. We're also going to be kind of really focusing on the idea of where that balance point in the water is because the body ability to adjust that positioning can be extremely important as you do the translation from in the water or excuse me on the land to in the water or potentially why they're actually having difficulty making that transition. And then a lot of these swimmers have grown up swimming. They've like myself, I started at age six and kind of moved through it all the way through high school and college and coach as well. And many of your kind of coaches, especially on the higher level will have experience. So they'll know some of the signs early on and they might have started attempting or adjusting kind of workouts or making technique changes to try to help mitigate something that maybe a swimmer is dropping distance counts or their times are trying to suddenly altering in practice. So there's maybe some things that they've started to already begin. They may not know why they may not hear from the athlete that they're in pain or having difficulty, but there may be something changing and that kind of gets into where are you in the training volume. And as Dr. Sherrier kind of pointed out, what part of the cycle, where are they in that periodization? Because that can change what you're going to start talking about and doing in the rehab component. And then always kind of looking at the idea of what can be translated from the land to the water. And that's going to be a lot of the difficulty. Dr. Kravac kind of really kind of made a good point with the fluid dynamics. And you've kind of heard all of our colleagues here talk about, you heard the words gripping the water, grabbing the water, pulling the water. And this is kind of something unique in the kind of swimming community where we'll talk about the feel of the water. Is this a fast pool? Is this a slow pool? How do we have a touch and kind of component? And it really is because we're going through majority of the time through a liquid surface and we're kind of interacting with it as it interacts back against us. So that perfect technique that we can see sometimes in an exercise on land, that we're like, yes, we made this strong, but then we throw them in the water and we have to worry about the balance. How do we even breathe? Because your face is underwater as you're moving. That can have significant effects of how that translate into the next stage. And it becomes somewhat of a cycle. You're going to be looking at the idea of how can we manage the pain of the moment, then looking at the flexibility and strength and the motion of a joint and particularly the shoulder in this location. So that does also include looking at the shoulder joint itself, the scapular thoracic rhythm, the scapula motion, the thoracic spine, cervical spine. And then as we extend down that kinetic change of how each part kind of interacts with each other, the integration of how are we changing those biomechanics? And this is going to be a huge role of kind of beginning that interaction and talk with the coaching, thinking about how are they new drills that they've been adding, or if we're focusing on a particular thing that we're having a hard time seeing that translation from the land to the water, they have an amazing amount of tools that they can bring up because their whole goal is to keep their swimmer swimming as long and as much as possible. So they may come up with new ideas, new drills, new ways to help kind of balance that out. And that kind of gets into our next phase of training of what can be adapted, what could be changed and what can't be. Where are our hard stops and what do we need to know when we need to stop, such as with our competitions? When is this a time where we say, no, this isn't a good time to try to put full effort forward and race, or maybe we need to back off and focus on the next component, next part of our cycle. And that really does come into a spiraling circle because when you look at the swimming, you can already heard that it's pretty much a year-round sport, but year-round primary, your kind of college and your elite swimmers, they're looking at about 11 months plus or minus two weeks out of a year that they're training and racing. And it's a continual biathlon four cycle, depending on the quad and where they're at in their training component, their primary focus may have spent six months to truly race for less than two minutes. Some of your Olympic athletes, just to make the team, you have to place first or second in the Olympics. And it's from there, they may have spent four years training for a race. That's only going to be a couple of minutes. So figuring out how to kind of integrate this and keep a swimmer swimming while you can help address their actual concerns is usually a large focus. If we go back to our kind of classic pathology beyond the swimmer soldier, there's the idea of the swimmer slouch. And Dr. Johnson already kind of brought this up that kind of forward head position, the increased kyphosis and that anterior kind of forward component of your chest. And this is an adaptive strategy you saw in Dr. Kravac's kind of lecture, where you're looking at the force pull underwater and what muscles are being activated, you're getting a lot of the lat, the subscapularis, the serratus, the pecs, and that's going to create a different translational force on the arm itself. And swimming has evolved, we've gone from a yard and pound kind of component where the original numbers we talked about, about 45 to 70,000 yards or meters per week. Some of the older teams were doing around 100 to 110,000 coming out. And that's a transition because coaching staff and USA Swimming has looked at the idea of how can we keep our swimmers, especially our elite swimmers, continuing forward and how can we make sure it's not just who survived the training, but who can actually thrive through the training. If we're just looking at the swimmer's slouch itself, that anterior humeral head, you're going to have that tight, shortened pec. It's going to have the increased tonicity and motion kind of coming through that periscapular muscles. Your scapula by nature, if that head's going to be anterior rotated, you're going to rotate and round through that scapular thoracic area. So now your scapular muscles are shorter, or excuse me, increased tone, but your humeral head is going to be affected by that tighter pec. It's going to have more of an internal rotation. Now, just from that by itself, we're going to put the humeral head and therefore your facets and your supraspinatus, your infraspinatus and your teres all in a different alignment in the shoulder joint itself. That is going to start resulting into different adaptive changes that we'll need to kind of address. And that kind of goes back to the idea of imaging. Where is an adaptive finding versus where is a, which is could be common. And where is a normal finding that we're used to hearing about versus where is a symptomatic problem. Oftentimes when I start working with swimmers, it's looking at the idea of that core stabilization, because we need to have that balance point in the water before we can start moving the extremities or kind of stabilizing through the thoracic or shoulders and kind of moving forward. That fluid dynamic component that we mentioned quite a bit. We talk about that from the balance point because not just a forward, backwards, up or down. It truly is balancing the whole body on a single point in space. So if you can think about that, take anything around you and try to balance it on just a pencil. It's your whole body. Maybe it'd be a water bottle or a phone if it's sitting next to you. And you've got to find that kind of minimal point that you can keep the body position. And a lot of our athletes are learning how to press their upper body, lift their low back, kind of tighten this muscle group or that to kind of keep themselves in that stabilized position. And that sometimes with the athletic trainers and personal trainers or physical therapists that I've worked with has led to them thinking, oh, they need to be strong in their core. But having a strong core does not necessarily mean that they're stabilized in the water and that translation back and forth. If we kind of move that up the chain, kind of getting to the thoracic region, the scapula is one of the biggest areas that I have a tendency to kind of really focus on. And this chart coming out of Kuhl's in the British Journal Medicine in 2014 had a really nice kind of diagram of how I like to start thinking about it. And what can truly have flexibility? If we're looking at our scapular muscles, if they're not having that flexibility, we're looking at the antagonist muscles groups, the levator scapula, the rhomboids, kind of looking at the pec minor, how are they moving compared if we're having more issues with the capsule, posterior capsule, infraspinatus, the lat. And how do we kind of address that? Is it more of a stretching mobilization component that we need to work on? Or are we actually having poor muscle control? So they're actually having good flexibility, but they can't actually control the motion in a dynamic component as they go through the water or they go from air to water or from land to water. Or is it truly a lack of strength that allows their muscle control to kind of fall apart as they kind of move forward? In combination of these, it ends up oftentimes, in my opinion, that we need to kind of get the positioning correct before we start looking and motor control before we start building strength. And that can be a very, very hard kind of issue. Because we go back to the idea of how many arm revolutions are we kind of going through in a general week, that becomes a motor matter, motor muscle memory component, that we truly have to engage the athlete in the swimmer to figure out how they can change that technique, getting those cues back to them working with their coach, helping them kind of learn that new motor pattern, which they may be perfectly on land, but once they go back into the water, it begins to kind of degrade back into habits that they've formed. That also gets in the idea of like dry land training, we can talk about doing these optimal muscle groups and how we can kind of move everything. But everything ends up becoming on a spectrum. And what we'd like to like to focus on is what can we strengthen? What's at what time are we strengthening it? This kind of study is kind of highlighting the idea. If we're just looking at a surface EMG, the weight load or an intensity of like a shoulder press, it activates. Different muscle groups at different times, or your kind of lower kind of yield to it or your shoulder press. As a result, we can kind of target different muscle groups, but swimming is a dynamic component where we're going through different viscosities. And as a result, these go into a sequence that biomechanical chain, we're trying to focus on strengthening each of these, not just an isolation. And then we have to start working on linking one muscle group to the next, as we go through the rehab. Very similar, kind of trying to emphasize this idea of the serratus and lower trap, lower and upper based on that kind of exercise component. Uh, if we just look at the serratus anterior, that shoulder press at a low intensity of three is high, kind of getting into that serratus dominant. But if we, well, that's a bad example because at eight, we're still pretty dominant, but if you're kind of going through the study and I believe that's still from the cool study, it will be able to help emphasize what I'm kind of trying to help make a point here. Maybe these press ups being here at a lower here, the lower trap versus upper trap coming across, um, looking at the fourth, number one, here's eight, and then one, two, three, four coming up. And you can kind of see how much more lower trap dominated versus an upper trap at a different kind of intensity. So we can kind of go through a lot of different motion patterns that kind of. Try to structure the strength of the shoulder itself versus the periscapular muscles. And I would say one of my mentors here at Michigan, uh, Dr. Aguson has really kind of forced me to really look at some of the biomechanics of how we do things in different positions. So many people are used to like the T's Y's and I's or maybe a shoulder press kind of coming forward, but we could add that into like an eccentric motion if we're worried about a strength and endurance component. Or they're actually having to hold that in position and we're kind of guiding it down. But if we're doing that, it is becoming one of those things. What is happening up chain at the kind of shoulder periscapular. Now, if we're also starting to worry about what's happening in the water, maybe having this in a isolated on a bench, it could be ideal, but maybe we need to put them on something that is more mobile. So once they're kind of optimizing this and showing stability and strength, maybe we should throw them on a physio ball or maybe on a banded components or a TRX component where their feet are elevated and they now have a more balanced aspect that they have to do with their core and stabilize the rest of their body while they're trying to maintain that kind of strength percentage that they're going. And that at the same time can help indicate when they're starting to have a degradation. Coming through a couple other examples of motions that I often will kind of work through with serratus, that serratus punch is something we often are aware of, or, uh, on the left side, uh, number B that kind of elevated arm. But that one, it would be a great example of where's the recruitment and what are we kind of focusing on? A lot of times I will see a lot of people having a lot of peck activation where I'm trying to work on the opposing muscle group. So how do we turn off what we don't, how do they kind of learn what muscle group, because they've know that they need to make point a to go to point B and they're athletes, they're going to do it. Is it the way that we want them and are they controlling the muscles the way and kind of progressing through and like the bear crawl on the bottom right corner, they're definitely a more dynamic and harder kind of positioning. And especially if you're adding a pushup plus to that and coming down, if they're trying to balance that core to be nice and flat for going into that lower trap, can we make the simple arm raise to a more dynamic kind of coming to like a downward dog with the toe touch and stabilizing through that arm in this example, you can see how that arm is already having that hyperextension kind of throwing the elbow. So that would be something I would say, are we truly actually stabilizing through the upper thoracic and shoulder and stabilizing through, or are we kind of moving through the motion? And that's where, again, how can we translate that back into the water? If we start talking about that integration, we learned about a lot of the different toys that swimmers love to use, and these can really still be helpful. Even though they can have an ability to harm or increase the risk of injury, these tools can provide a chance to alter training or allow us to kind of look at focusing on key components that they may be falling apart on. Your snorkel is a great tool to kind of, especially if we're having issues with rotation while breathing or hip to shoulder ratio of rotation in their stroke, where we truly can get a second chance to be able to stabilize one part, letting the body move forward. Maybe that's talking about doing the same thing, but throwing a mirror underwater so they can actually see themselves going through the stroke and have those cues kind of coming through. Fins are another great example because I can increase the load on the legs, sometimes help with the body elevation and body positioning. If they're having a difficulty in that core stabilization that we know we got to work on, but then we can just focus more on the shoulder while they're in the water and allowing the kick to kind of raise them up. Similar idea with the pull buoy. And yes, even the paddles that we sometimes don't want, but that can be brought back to the idea of how do they feel the water? Can we use that to kind of help them learn an early catch or body positioning? You'll see sometimes swim teams where they'll actually take off the band. If you look on the paddles, the black and kind of turquoise, you can kind of see a finger spot, which would kind of go around your middle finger and then the wrist. Further down, they may actually have you pull out that wristband because if you have a bad entry or not able to help keep your hand at a good entry point, your paddle actually will rip itself off your hand. So it's a way to help kind of teach where is your body in the water, but how are you actually starting to feel the water and catch the water and that it can allow that upstream effect into the shoulder periscapular and thoracic area. And that kind of gets the idea of the sculling and drills and what can the coach kind of bring in to help you in this kind of integration. I've had the benefit of talking and working with a lot of our national level physical therapists and athletic trainers and coaches, and they kind of all echoed something when I reached out to them more recently is the idea that the shoulder pain itself is often a signal of something not moving correctly, often a movement pattern, and it's been emphasized throughout our whole series that watch the swimmer move, see how they're kind of moving through it. Where is things kind of falling apart? And it doesn't need to be something that you need to be an expert on. You can simply ask the swimmer, how do you move and how do you want to move? And they can indicate oftentimes what is kind of falling apart that they're kind of being worried about. And a lot of times they're talking or partners are talking about the idea of that fear. If we do get imaging or something else, they may be told, yes, you have a labral tear or you have multidirectional instability of your shoulder. But is that really something that they need to focus on or is it something that is a result of or an adaptive changes? So when we started working on our kind of rehab progression, especially in the season or what they're kind of progressing to, we need to keep that in mind as we start adapting our rehab progression for that athlete, how we approach like a 13 year old that's going through a growth spurt and maybe a butterfly is very different than we're talking about, like a D1 sprinter chasing a trials cut or maybe just made a national team and they have maybe two months before they're going off to the wugs and kind of moving forward. So a lot of this kind of comes down to that discussion with the athlete and oftentimes really incorporating the coach if you can to help you kind of move forward, which really does come back to that returning to water. How can we get them swimming as much as we can? Talking with the coaches will be one of the biggest things because there are ways to keep a swimmer swimming. And if we're talking, they have shoulder pain. If you decide they cannot do overhead motions, then what prevents them from kicking? What can prevent them from doing skull work? What prevents them from doing anything in the water that we can be adaptive to? A lot of times when that athlete is out of the water, these swimmers have grown up swimming like Ryan or yeah, sorry, Ryan, Dr. Scherrier brought out a lot of the early age group is six and are in under is our largest kind of cohort within USA Swimming. But as that swimming group cohort ages, as they go through 9, 10, 11, 12 and into the senior groups and progress, that means when we see them, especially in like the college level, they've spent more than half their life swimming. This is the people they know. This is what they continuously do. Their teammates are always around them. They may be spending 20 hours a week in the water. So if we start pulling them out because they say you can't swim, there's going to be secondary effects on that emotional or identity component that they have. And it can have secondary ramifications, not just on the swimmer, but on how the team perceives. Should they talk to you? Because they just saw their friend be pulled out of the water and they can't swim when they say shoulder pain is normal. Shouldn't be something we should be worried about. Dr. Scherrier had a great study that he showed up at one, two NSAIDs a week. They think it's normal. So how can we keep them moving forward? How can we keep them swimming, but also keep them swimming safely? And really, I think the biggest thing I would kind of bring back is that idea of it's a cycle. There's always kind of a progression of how can we help manage the pain? How can we work on the motion patterns and that bio kinetic chain? How can we work on the integration into the water? And when do we use that to switch over to training and competition and working on that load component? My general references. And then I will kind of highlight the fact that Dr. Krebek and Prajak Singh is kind of our, I'd say, guiding parents of our small swim family here. And right now, Dr. Scherrier and Johnson, myself and Dr. Elm are kind of all siblings. And we do have, I know, some growing people in the next wave that are just coming up that are heavily involved and interested already in swimming. So hopefully, as we kind of go through this talk, we can inspire a couple more to join our cohort and join our swimming family. Well, thanks, thanks, everyone, for thanks, particularly for the speakers for all that great content. I just want to open it up to some questions. Maybe we can do like five or 10 minutes. I know we're running a little late. And Dr. John Sianka had a question for you, Adam Love. Now, what makes a pool fast or slow? Is there is it a feel scenario or what? Help us out with that lingo. There are many different things that can be said on that idea. It is often a lingo that you'll hear from a swimmer about how they feel in the water, how they hit their taper, how they actually feel the water catch. Truly from a sport specific, it's going to be the idea of the depth of the pool, as well as how the lane lines themselves will flow the water around you. And then how does the water get to the gutter? Is it a drop gutter? Is an overflow? And by that, what I mean is as you're swimming by yourself, you can think about from Dr. Kravitz lecture, you're seen even just with that single swimmer. You can see the water spiral out, the bubbles coming forward, that impact that you have as a swimmer itself will have impact on the people around you. So it's not just the fluid dynamics that you have that you're swimming with. You're also creating water flow differences around the people around you. And that kind of transitions. So a lot of the faster pools will have a way to help mitigate that to some degree and how they actually circulate water through the pool can have some effect on the perception of speed in the pool. But again, that's scientifically most of your swimmers are going to say this is a fast pool just because of how they actually feel they're gripping the water. Yeah. And then to add on to that, this was an issue in Paris, right? If you were watching Paris, I mean, talked about the pool. But those of you are not aware for big events like Olympic trials in Paris, they actually build the pool. So in Paris, we were centered in just a big indoor stadium, in essence, an indoor stadium. And in L.A., it'll be in Sophie Field, I think it will be. So they build these pools. And ironically, in Paris, it had something to do with parking or something underneath that. So the depth was not what the athletes were used to, although the company that builds the pool is very adept into dealing with a lot of these issues of flow of the water through there. But in the case of Paris, people were just complaining because they had heard the pool was not as deep and therefore it was quickly labeled a slow pool. I will say, though, with Paris, you know, everyone was complaining it was a slow pool and then all of a sudden, I think it was a Chinese athlete, I may be wrong on that, like broken either a world record or Olympic record. And then all of a sudden everyone started breaking records. So it's also like the mindset of the athlete. You know, there's rumored very fast pools and there's rumored slow pools. And it's it's maybe just a little bit placebo in their heads. Anyone with any additional questions? It looks like we have a question from Abraham saying, what exercises are used to isolate supraspinatus muscle without contracting deltoid for strength, endurance training and rehab? If anyone has any thoughts on that. I don't know if you can fully isolate 100 percent without the deltoid, and I'm not sure if I fully would want to just supraspinatus by itself because the deltoid will be involved in the stroke mechanics itself. In some of my athletes that are having more of that supraspinatus concern, the overhead Y&T, I'll kind of usually bring that arm into more of a shoulder scaffolder position, isolated, usually on a bench to start or a bed to kind of give a little bit of anterior support and then bring the arm over the edge. So kind of like an angle out and I'll give them a weighted component and have them kind of do almost a straight arm down at that kind of Y angle to see if I can isolate that a little bit more and alter the arm positioning until I can find position where we can kind of stabilize. But the big thing there is if I'm in that position, I want to make sure that they can maintain the scapular kind of plane and stabilization to that shoulder and trunk before I let them kind of truly add weight or kind of a resistance component. If they are able to kind of do that and maintain, oftentimes they're going to be surprised because I can give them just like a five pound weight and say, hold that there and try to stabilize it in almost an isometric. And then from an eccentric, normally I'll give them a little bit heavier weight and I'll kind of guide their hand down with it, kind of an assisted eccentric, and I'll bring them back up. Once they're able to kind of move forward from there, then I'll start trying to challenge that kind of scapular area without the assistance of the bed or the table and kind of move them a little bit forward so their trunk is a little bit more off or maybe add in some kind of balanced component under their core or lower body that has to be stabilized as if they're in the water. And I think this highlights an important part, which is the team and the therapist that you work with. It's not uncommon where I'll have patients come in and they've seen someone for shoulder pain. They do their rotator cuff and they all go like this. I'm doing my exercises. Look at me. Why aren't there any better? And what you really realize is that they haven't connected the chain, the balance, as Dr. LeBlanc just talked about. And for me, I like to actually have them close their eyes when they're on uneven surfaces and challenging that because that engages your proprioception and athletes get the idea of the feel of the water, the feel that they have, the repetitive motion of that. And if you get them to close their eyes, they really have to concentrate on engaging the scapula, engaging the core, thinking about how they're going to move forward engaging the core, thinking about how they're feeling that motion and movement as you do some of those PNF style of movements as well. And I think that's a good thing to challenge your athletes on because most of them won't, they'll be like, wow, somebody, I never realized like I had to close my eyes and get this feel for it. And it's a great way to really engage them. And I would agree. You're not really as much isolating out the supraspinatus because it's the complex nature of everything together. That is the important component of it. I have a question. I'm just curious. So I'm at Duquesne, which is a non-power for college and you have a swimmer coming in with shoulder pain and you broached the subject of, has anyone ever looked at your stroke? And then you come to realize that program doesn't own a camera or anything. And you're just like, oh, geez. I'm just kind of curious at a collegiate level, how you've seen it work well. I mean, when looking at all the different factors, particularly a stroke assessment, is that best done with the coach and you and the athletic trainer or what system have you seen work well at like a collegiate level? Or is this something where coaches just want to take this and own it? I guess I'm trying to hear your insights on this. I think it's a great question. I can speak to our experience kind of at like the mid-major D1 level. And I think a lot of this will depend on your resources. Certainly. I think it's, at least where we were at, it's very common to have filming and practices and there'd be sessions where you sit down and kind of look at the film with your coaches. And so they'll have one typically kind of above water and one underneath the water, typically kind of from the side, but sometimes in front as well. So I think they'll have access to them. I mean, at least they should. And if they don't, I mean, I think an athletic trainer would be very willing to film if you're going to chat with them. Okay. Do you mind just filming them from the side so we can take a look at what's going on here? Curious to hear other thoughts. Yeah, I think there's opportunity, right? A lot of these images, Russell Mark, they're really just like an iPhone put underwater and they just follow them along. And so they'll film from above. So the technology's narrowed down that you don't need some like high-tech system to look at this. My biggest word of advice is establish that relationship with the coach, but understand the boundaries, right? When I'm at the Olympics with the coaches, I'm not telling them technique, right? I'm trying to engage a conversation around this. And the biggest mistake you can make is going in as a physician and being like, oh, you're not teaching the correct technique, right? You need to do this, right? There's a subtlety to that. You can perhaps get away with it at that age group level, but really the coaches want to kind of understand what's going on. And if you can develop a good relationship, they'll keep sending you kids. And then you establish the other team members, that physical therapist or yourself to work through that. But at the beginning, you can simply use like the devices you have to film them and look at that and just get a good stick to put your iPhone on and just, you have to feel comfortable putting it the water because they actually are not waterproof, but can be water resistant as well. And so that's a good way to start. It looks like I got about maybe one minute left. I don't know if anyone has any final question. Okay. I don't know. I mean, amongst all the speakers, I mean, I feel like you got to make your own community here. I think there maybe needs to be a swimming community. Maybe that's already in the works, but the content was tremendous. Really appreciate all of your expertise. To echo that, and I think Adam brought this up earlier, Dr. Varno, feel free to reach out. There is a core group of us, people included on this, who will get together at different conferences and just kind of discuss things and kind of provide future past knowledge from our experiences to future knowledge and opportunities that are there. So feel free to reach out.

swimmer's shoulder

overuse injury

competitive swimmers

biomechanics

rehabilitation

evaluation techniques

stroke analysis

training loads

video analysis

shoulder musculature

swimming epidemiology

kinetic chain