Shoulder Pain - When to have an MRI

Shoulder pain is the most common pain complaints in swimmers. Studies have shown that between 47 and 73 percent of musculoskeletal problems in swimmers relate to their shoulders. It is no wonder these injuries are so common considering that an elite swimmer may log up to 20,000 yards per day. Or consider the college or high school swimmer who is averaging 5,000 yards per day, five days per week, for 10 months per year. If one has an estimated 15 individual arm movements per 25-yard pool, this would account for over 600,000 arm movements per year. Yes, it is easy to see why a swimmer may end up with shoulder pain.

The first order of business is to make sure that one’s exercise regimen and/or swimming technique is not the problem. Pete Alfino, Level II USAT Certified Coach and founder of Mile High Multisport in Highlands Ranch, Colorado notes, “A lot of shoulder injuries are caused by improper hand entry into the water. Proper hand entry begins with proper recovery and positioning of the hand and elbow during the recovery. Your elbow must remain higher than your hand during your recovery phase of your stroke. Often I witness the elbow or palm of the hand hit the water before entry. The ideal hand entry begins with your fingertips entering the water as if it is entering a mail slot. Most novice swimmers I watch enter with their thumb first. This causes additional strain on the shoulder. Ideally, you want your palm flat (elbow elevated) and a slight cock in the wrist (no limp wrist or broken wrist entry). Have swimmers concentrate on the pinky finger entering the water first as opposed to the thumb. This reduces the tension on the shoulder.”

If a change in swimming technique or exercise regimen does not help with the pain, then some type of treatment is needed, such as physiotherapy. If more conservative treatment does not resolve the pain, is it time for an MRI?

Here are some indications that an MRI may be suggested:

Pain is Extreme While Swimming

The swimmer who has failed conservative measures, and still has extreme pain with swimming most likely has some soft tissue damage. A ligament, tendon, or labral tear will need to be addressed by more aggressive measures versus just exercise.

Shoulder Clunking

The shoulder joint is the “loosest” joint of the body. It has some ligament and labral tissue support to keep the shoulder joint stable, but the shoulder was made for movement. When the shoulder becomes unstable, or hypermobile, it can start making a clunking or clicking noise. When the shoulder clunks or clicks with each stroke, it can indicate a more severe shoulder instability that will need to be addressed. An MRI can show which tissues are damaged or injured.

Dead Arm Syndrome

While this is more common in pitchers, swimmers can also have the feeling that they have no power in their arms. When a swimmer’s pull becomes ineffectual, there seems to be no power in the pull portion of the stroke. This can be another sign that a swimmer’s shoulder is loose and unstable. The muscles only have power when they contract against a stable base. When the pectoral and latissimus dorsi muscles contract to give the swimmer power with the pull, these muscles need the shoulder ligaments and labrum to hold the shoulder joint in place. If the shoulder is hypermobile, or too loose, then the muscles lose a lot of power. For the swimmer with dead arm syndrome, an MRI may be ordered to determine if a tear in the soft tissue (ligaments, tendons, or labrum) that stabilizes the shoulder is present. 

Tyranny Of The Urgent

While I do not think athletes should make medical decisions based on big events, big events are part of sport. An MRI may be indicated for an athlete who is two months out from Nationals competition and experiences sudden shearing pain of the shoulder. If something is seriously wrong with the shoulder, such as a labral or rotator cuff tear, it needs to be identified so that training or treatment regimens can be adjusted.

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