Swimmers and Divers, How Does Surgical Intervention Change? Ben Rubin, M.D. Orthopaedic Specialty Institute Orange, CA.

Swimmers and Divers,How Does Surgical

Intervention Change?

Ben Rubin, M.D.Orthopaedic Specialty Institute

Orange, CA

Is There a Difference in the Surgical Treatment of Shoulders in Swimmers

and Divers?

Swimmers vs. Divers

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

Diving Kinematics

• Phases– Approach – open chain– Press – open chain– Flight – open chain– Entry – closed chain

• Arm position

Diving Kinematics

• Arm position

Swimming Kinematics

• Phases– Catch – closed chain

• Hand entry• Catch

– Pull through – closed • Insweep• Finish

– Recovery – open chain• Arm position

Body Characteristics

• Postural dysfunction

Body Characteristics

• Postural dysfunction• Scapular dyskinesis

– Proximally derived– Distally derived

Body Characteristics

• Postural dysfunction

• Scapular dyskinesis

• Joint laxity

Body Characteristics

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

Body Characteristics

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

Mechanisms of Injury

• Always try to correlate symptoms with mechanics of sport

• Diving– Pain with front throw or back throw– Circling– Entry

• Swimming– Catch, pull through, recovery

Entry Statistics

• Velocity– 1 meter 18.75 mph– 10 meter 36.8 mph

• Force at impact– 2.0 – 2.4 Gs

• Submerged 128-140 msec

• 53% decrease in velocity• All without a splash

Mechanisms of Injury

• Diving– Macrotrauma

• Dislocation, subluxation• Occasional RCT with dislocation

– Microtrauma• Repetitive subluxation (assoc. RCT)• MDL becoming instability• Scapular dyskinesis (proximal vs. distal)• “Overuse” – capsule and/or cuff strain

– Usually associated with laxity/instability

Mechanisms of Injury

• Swimming– Microtrauma

•MDL becoming instability•Scapular dyskinesis (scapulothoracic

weakness or imbalance)•“Overuse” – capsule and/or cuff strain

– Macrotrauma•Injuries out of the water

Shoulder Pathology

• When evaluating the shoulders of young athletes, be careful not to describe symptoms (biceps and/or cuff tendinitis, “impingement syndrome”, etc.)

• Make a core diagnosis which explains the symptoms

• Primary SAI is extremely rare in swimmers and divers

Shoulder Pathology in Divers

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

Shoulder Pathology in Divers

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

Shoulder Pathology in Divers

• Labral tears and detachments– ALPSA lesion

Shoulder Pathology in Divers

• Capsule attenuation– Unidirectional

instability– MDL with UDI– MDI– Rotator interval

lesion– HAGL lesion

• MGHL deficiency (congenital)

Shoulder Pathology in Divers

• Rotator cuff tears– Partial thickness

• PASTA lesions• Tensile failure

– Full thickness (rare)

• Internal impingement (rare)

Shoulder Pathology in Swimmers

• Capsule attenuation– MDL unidirectional instability– Unidirectional and MDI may be a

continuum– Rotator interval

• MGHL deficiency• GIRD• Tensile injury to cuff

Correction of Pathology

• Evaluate and modify technique prn• Correct scapular dyskinesis if

proximally derived• Teach scapular positioning if

distally derived– Program must be sport specific

• EUA (always compare sides)• Diagnostic arthroscopy

Surgical Correction

• Suture capsulorrhaphy• Rotator interval plication prn

Surgical Correction

• Bankart repair with suture capsulorrhaphy

Surgical Correction

• SLAP repair

Surgical Correction

• Rotator cuff repair or debridement

Surgical Correction

• Reexamine under anesthesia– Insure stability without compromising

ROM required for sport– Refine rehabilitation based on postop

ROM and stability

Rehabilitation

• Core based functional rehabilitation which is sport specific

THANKSFOR

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