When Shoulder Hypermobility is a Problem

Athletes who participate in shoulder-stressing sports, such as tennis and swimming, often experience laxity, or looseness, in their shoulders, with female athletes normally having more shoulder laxity than male athletes. Certain sports stress different structures in the shoulder. Swimming tends to stress the anterior inferior structures (the front of the shoulder) during the backstroke and the posterior ligamentous support (the back part of the shoulder) during the pull-through phase of freestyle. The common denominator though, is excessive looseness of the shoulder joint.

The shoulder joint is essentially a free-floating ball suspended in a ring of ligamentous tissue. The rotator cuff muscles are the structures that move the shoulders. When the supporting structures of the shoulder become excessively hypermobile, the rotator cuff muscles are called upon to stabilize the shoulder, as well as move it. Eventually these structures fatigue and the swimmer is left with a rotator cuff tear, injury, or tendinopathy. In such a scenario, the real cause of the injury is shoulder joint hypermobility. If the training schedule is not altered and the swimmer continues training the same way, the swimmer may eventually suffer from shoulder misalignment, dislocations, or tears.

What can be done in this situation? There are four simple solutions when shoulder hypermobility goes from physiologic to pathologic and becomes a problem for the swimmer.

1. Stop dryland exercises that increase shoulder joint laxity. If a swimmer has a loose shoulder, then activities such as yoga and passive stretching of the shoulder should be discontinued.
2. Allow time for ligaments to tighten after workouts. Aggressive training exercises cause ligaments to elongate. If an athlete’s training regimen is appropriate, sufficient time will be allowed for the exercised joint structures to remodel and repair. The amount of time required for this to occur is individualized for each swimmer. For the swimmer with shoulder hypermobility problems, swimming training hours may need to be reduced or the regimen may need to be altered. This might mean adding sets of backstroke instead of freestyle, which stress the opposite structures of the shoulders. Other times it may mean that rest days need to be incorporated into the swimmer’s schedule.
3. Add appropriate strength training. The easiest way for an athlete to tighten up loose ligaments is to strength train. For swimmers with hypermobility issues, exercises that work all the shoulder muscles within a pain-free range, including the scapula stabilizers, should be incorporated. Strength training causes muscles to tighten, which can have a protective effect for the athlete with problematic hypermobility. Strength training of the shoulder should be not be attempted without first seeking the advice of health care practitioner with a rehabilitation/sports medicine specialty to get specific shoulder exercises, since just working shoulders in the gym may aggravate a shoulder problem.
4. Assess your technique. You knew this one was coming. For the swimmer with a painful shoulder, certain technique skills must be checked to ensure that excessive stress is not being placed on the shoulder. This includes increasing body roll, maintaining a high elbow, and avoiding excessive elbow extension before beginning the hand in-sweep.

In any swimmer with significant pain, an accurate physical examination and diagnosis is important. If pathologic joint laxity is identified, all potentially contributing factors should be identified and altered if possible.

Ross A. Hauser, MD, 47, has completed numerous endurance swim events, in addition to five Ironman Triathlons. He received his undergraduate degree from University of Illinois. He graduated from the University of Illinois College of Medicine in Chicago and did his residency at Loyola/Hines VA in Physical Medicine and Rehabilitation. Dr. Hauser is the Medical Director of Caring Medical and Rehabilitation Services in Oak Park, Illinois