Dante Dettamanti BS, MS
Coached Stanford University to Eight NCAA Championships
This is the first of two articles on shoulder injuries to water polo players. Over the years I have seen many water polo players with shoulder injuries, some that were minor and only lasted a few days, and some that required surgery and forced the player to sit out the whole season. Some are even career threatening. What causes these injuries and what can be done to prevent them? The second article describes why water polo players get shoulder injuries and then presents a series of exercises that can be done to prevent the injury from happening in the first place.
THE SHOULDER JOINT
The shoulder joint is a truly remarkable creation. It's quite a complex formation of bones, muscles and tendons and provides a great range of motion for your arm. The only downside to this extensive range of motion is a lack of stability, which can make the shoulder joint vulnerable to injury. Injury to the shoulder is the most common water polo related injury. This is no surprise considering that the shoulder joint is the most used joint of the body when playing the sport of water polo. Hundreds of hours of swimming and overhead passing and shooting are bound to stress the shoulder to the point where an injury occurs.
WHAT COMPRISES THE SHOULDER JOINT?
The shoulder is made up of three bones, and the tendons of four muscles. (Remember, tendons attach muscle to bone.) The bones are called the "Scapula" (shoulder blade), the "Humerus" (upper arm bone) and the "Clavicle" (collarbone). The four muscles which make up the shoulder joint are called, the "Supraspinatus," the "Infraspinatus," the "Teres Minor" and the "Subscapularis." Each muscle originates on the shoulder blade, or scapula, and inserts on the arm bone, or humerus.
The shoulder is made up of two main joints, the glenohumeral joint, which is the “ball and socket” joint, and the acromioclavicular joint, which is the smaller joint above the glenhumeral joint. The shoulder has an extremely large range of motion (more than any other joint in the body) primarily due to the lack of bony congruency, and the very shallow cavity of the glenoid, which holds the ball at the end of the large bone of the arm, the humerus. Because of the shallow socket of the shoulder joint (glenohumeral joint), it is difficult for the ball of the humerus bone of the arm to stay in place when the arm is rotated; especially when the arm is in an overhead position.
The four small individual muscles described above, and more specifically their tendons, surround the shoulder joint to form a thick "cuff" over this joint, called the “rotator cuff.” It is the tendons of these muscles which connect to the bones, that help to move your arm. When an injury occurs to the rotator cuff, it is usually an injury to the tendons of the rotator cuff muscles. These muscles are small, but their function is very important. Specifically, they act to keep the shoulder joint stable during movements of the arm by, in layman's terms, keeping the 'ball' in the 'socket'. They also help in elevating and rotating the arm.
The scapula has two bony projections – the acromion, which attaches to the clavicle (collar bone), and the coracoid, which is a beak-like projection to which the biceps muscle is attached. These projections form an arch above the shoulder joint called the coraco-acromial arch. The tendons of the rotator cuff muscles pass under the coraco-acromial arch and attach to the humerous. Movement of the rotator cuff tendons beneath this arch is aided by the presence of the sub-acromial bursa, a bag of fat preventing friction between the muscles and the bones. (See Diagram down below)
The rest of the shoulder socket is formed by ligaments (connect bone to bone) that connect various parts of the bony components of the socket and cartilage (labrum) around the small rim of the bony socket. The shoulder is the only joint in the body that is not truly held together by ligaments. The few ligaments in the shoulder serve only to keep the shoulder from moving too far in any one direction. The ligaments have little to do with holding the joint in place.
The large muscle that surrounds the outside of the shoulder, and forms the pad of the shoulder, is called the deltoid. The rotator cuff tendons and both the shoulder joints lie beneath the deltoid. The deltoid’s main function is to lift the arm out to the side, or in front of the body. It also can help to stabilize the shoulder joint; especially when the arms lift overhead against heavy resistance.
WHAT CAUSES INJURIES TO THE SHOULDERS OF WATER POLO PLAYERS?
Athletes with a long history of participation in sports involving repetitive overhead motions or throwing, such as water polo, swimming, volleyball or baseball, are more prone to suffering injuries to the shoulder. Water polo players are prone to shoulder injuries from both direct trauma and overuse. The most common cause of physical trauma when the arm is in an extended overhead position, is when the player is in the act of shooting, and has the arm pulled back from behind.
Many water polo players start as competitive swimmers and have accumulated a lot of mileage in the pool before they even pick up a ball. Overuse is caused by the repetitive rotation of the shoulder joint, especially when performing the crawl or butterfly swimming strokes. Add to this the stress from taking thousands of overhead shots and passes, and the result can be pain, numbness, and weakness in the shoulder joint; sometimes resulting in the inability to move the arm or shoulder.
The repetitive stretching of the shoulder capsule and ligaments that occurs over time causes the shoulder to become loose or unstable. The “tightness” of the ligaments, tendons and the muscle cuff around the shoulder is important for the joint to maintain its integrity. Heredity also plays a part in the integrity or stability of the shoulder, as some are born with so-called “loose” shoulders; which technically are loose tendons and ligaments around the shoulder joint.
With the stretching that occurs in the shoulder tendons over time and overuse, it doesn’t make any sense to stretch the ligaments any further by performing shoulder-stretching exercises. When doing a stretching exercise, the muscles will reach a point of full stretch. Forcing the muscles to go past this point will cause the tendons connected to the muscles to be stretched even more, and possibly cause strains and tears to the muscle and tendon.
Forceful stretching of the shoulders of a swimmer or water polo player (hands behind the head and pulling both elbows back) by another person is even more dangerous; because the person doing the stretching does not have pain as a guide as to when to stop. The result can be to stretch the tendons of the shoulder even more; resulting in a looser shoulder that will be more subject to injury.
COMMON SHOULDER INJURIES IN WATER POLO, SYMPTOMS AND TREATMENT
The most common shoulder injuries to water polo players are shoulder impingement, rotator cuff tears, bicipital tendonitis and labral injury. Other injuries to the shoulder like shoulder dislocation or partial dislocation (the ball slips out of the socket) are rare in water polo; but they can happen occasionally. They require a forceful blow to the front of the shoulder when the arm is outstretched or overhead. Dislocation can also occur in swimmers and water polo players with a long history of overhead motions or throwing.
This injury is common among water polo and other sports that involve repetitive overhead motions or throwing. During normal shoulder motion, the rotator cuff tendons and the subacromial bursa travel smoothly beneath the acromion in the space between the acromion and the head of the humerus bone. In addition the bursa, a small fluid filled sac, helps the rotator cuff travel smoothly beneath the acromium and the AC joint. In shoulder impingement, however, the rotator cuff and bursa get pinched, or impinged, underneath the acromion during overhead activities, resulting in pain.
Several factors can contribute to shoulder impingement. Structural abnormalities that some people are born with, or development of bone spurs with aging, can cause a narrowing of the subacromial space. The less room for the rotator cuff and bursa to travel, the more likely these structures get pinched during shoulder motion. For water polo players, however, the most likely causes are inflammation and shoulder instability.
Overuse or repetitive irritation of the rotator cuff underneath the acromion can lead to inflammation of the rotator cuff tendons and overlying bursa (tendonitis and bursitis). Not only is the inflammation painful, but the pain is aggravated when these inflamed structures get pinched or impinged underneath the acromion during overhead motions.
Instability is caused by a loose structure supporting the shoulder. The rotator cuff muscles are not meant to function under stress with the arm above a line parallel to the ground. If the shoulder joint is continually stressed with the arm in this overhead position, the rotator cuff muscles begin to stretch out. This allows the head of the joint to become loose within the shoulder socket.
If the head of the shoulder is loose, as you extend your arm backward over the shoulder, the head will slide forward, catching the tendon of the short head of the biceps between the ball and the socket. The supraspinatus muscle tendon may also be impinged. This impingement causes the tendons to become inflamed and painful. Athletes such as water polo players, and free-style and butterfly swimmers, who feel pain deep in the shoulder are usually impinging the supraspinatus muscle.
Athletes typically experience gradual pain in the front and side of the shoulder that is aggravated by reaching or overhead activities. They might have decreased range of motion and subjective weakness, with difficulty raising the arm overhead or behind the back. Night pain and difficulty sleeping on the affected shoulder are also common.
The good news is that the symptoms of impingement can be treated at home. Water polo players should rest the injury by avoiding repetitive overhead activities, or aggressive activities, until pain and inflammation subside. Anti-inflammatory medications (e.g. ibuprofen) and ice might also be helpful in reducing pain and inflammation. Pain free range of motion exercises and strengthening exercises should be started as soon as possible, but only under the supervision of a physical-therapist.
Most athletes improve with conservative treatment and gradually return to action after attaining pain-free range of motion and full strength in the muscles. Return time varies from a few weeks to a few months, depending on the degree of the symptoms and extet of the injury.
If symptoms persist, the athlete should consult a sports medicine professional. Formal physical therapy may be needed to assist in decreasing inflammation and pain. This may include ultrasound, electrical stimulation, cortisone injections, etc. As a last resort, athletes who continue to have disabling symptoms may require surgery to correct the problem. If shoulder impingement continues over time, the repeated inflammation and irritation of the rotator cuff might eventually cause the cuff to wear down, degenerate or tear.
ROTATOR CUFF TEARS
Rotator cuff tears are a common injury of a complicated joint. The Rotator Cuff is one of the primary areas of shoulder trauma. When someone has a shoulder injury, chances are very good that is related to injury in the Rotator Cuff. This trauma can be due to sudden injury, or can be from overuse in undesirable movement patterns.
The most common symptom of a rotator cuff problem is pain. Players usually complain of pain over the top of the shoulder and arm. In some players, the pain can descend down the outside of the arm all the way to the elbow. The other common symptom of a rotator cuff tear is weakness of the shoulder. Weakness causes difficulty lifting the arm up overhead or out to the side, and difficulty with activities such as reaching, getting dressed, or carrying objects.
An acute tear tends to happen as a result of a sudden, powerful movement. In water polo this can occur following a powerful throw, or having the arm pulled back by another player while it is extended over the head. A single or repeating rotator cuff injury, usually affects the subscapularis muscle of the rotator cuff. Other symptoms beside those described above include:
A chronic tear develops over a period of time, when repetitive overhead motions over many years cause stretching of the tendons and the resulting loose shoulder (As described under “Impingements) above). The tears usually occur at or near the tendon, as a result of the tendon rubbing against the overlying bone while the shoulder is in an unstable and loose condition. The impingement of the rotator cuff in a narrow coraco-acromial arch also leads to progressive injury of the supraspinatus muscle, which forms the upper part of the rotator cuff. Additional symptoms include:
Conservative care as described under “Shoulder Impingement” above (rest, reduce pain and inflammation, restore full range pain free range of motion, and strengthening program) can also be implemented for minor tears. Surgery may be necessary if symptoms persist after conservative care. Larger tears to younger athletes who are very active may require early surgery. An MRI will probably be required to show the location and extent of the injury. A full return to action from a rotator cuff tear can take up to three months, depending on the size of the tear, the symptoms, the degree of weakness, and whether surgery is required or not.
Another common injury to water polo players is tendinitis of the biceps tendon as it passes up the upper arm bone (humerus). Because of its location, the tendon is prone to irritation and inflammation by the same mechanisms that cause shoulder impingement. During overhead motions the biceps tendon can be pinched or impinged between the head of the humerus and the acromium, leading to inflammation and pain. Although most cases of bicipital tendinitis are related to shoulder impingement, it occasionally can be related to overuse in swimming and water polo from stress placed on the tendon from repetitive motion and overhead throwing; or even from doing arm curls with weights using improper technique.
Symptoms include gradual pain over the front of the shoulder that might radiate down the biceps muscle. Treatment is very similar to the conservative treatment described for shoulder impingement, with additional treatment of cortisone shots or even surgery in extreme cases. Return to action can be from anywhere a little as two weeks up to as much as two months depending on the severity of the injury.
Have you ever had a deep, ill-defined shoulder pain with an associated painful clicking, popping or catching sensation? You probably have an injury to the glenoid labrum, which is the dense cartilage-like rim that surrounds the shoulder socket (glenoid); and serves as the anchor point for the shoulder capsule and ligaments that help stabilize the shoulder. Injuries to the labrum are again part of the overhead repetitive syndrome associated with swimming and water polo.
When the head of the humerus slips out of the glenoid, a tearing or detachment of the labrum can result. The long head of the biceps tendon attaches to the labrum, and repetitive traction to this area from the throwing motion can also cause a strain or detaching of the labrum. Symptoms as described above can occur from an initial traumatic event; but many symptoms occur gradually over time and from the labrum getting caught in the glenohumeral joint during motion. Pain might be reproduced with the throwing motion or when reaching overhead, which can make a labrum tear difficult to distinguish from shoulder impingement symptoms. Many times the diagnosis of a labral tear is made by MRI or during surgery.
The management of labral injuries follow the same guidelines as prescribed above for other shoulder injuries. As in other injuries, if the injury does not respond to conservative treatment, physical therapy, or cortisone shots, then surgery might be considered. If a labral tear is not healed initially, it is unlikely to heal over time. If a labral tear is continually aggravated or stressed through participation in sports activities, the injury could become worse, resulting in more painful symptoms. If the athlete cannot return to action after a relatively short recovery period of 3-12 days, then surgical repair of the torn labrum has to be considered.
QUESTIONS AND SUMMARY ON WHAT TO DO ABOUT ROTATOR CUFF INJURIES.
When should I seek medical attention for my Rotator Cuff Injury?
Seek medical attention if:
What can I do to help my rotator cuff muscles recover?
Treatment for an Acute Rotator Cuff Tear:
Most rotator cuff tears can be treated without surgery -- in fact, it is the small minority of patients who end up undergoing surgical treatment for a rotator cuff tear. However, if the injury is quite severe and you are young and active, you might require an operation to fix the tear.
Indications for surgery might include:
Treatment for a Chronic Rotator Cuff Tear:
How long will it take to get better?
The water polo athlete should never try to diagnose or treat any injury in the shoulder area by himself/herself. A trainer should be consulted (if your school has one) immediately when pain, or any of the above symptoms are noticed. If conservative treatment of ice, medication and rest does not solve the problem, then a doctor should be consulted.
[Click Dante's photo to learn more about his water polo experiences and
Click one of the water polo balls to learn where to buy Dante's books.]
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