When Can Physical Therapy Prevent Surgery?

by Sally Fansler, PT

While more than 1.5 million orthopedic surgeries are performed in the U.S. each year, current research is showing that surgery might not be needed as often as previously thought. According to a recent review an estimated 10% to 20% of surgeries might not be necessary and in some specialties - such orthopedics - that number could be higher. One of the most common reasons for unnecessary surgery is that conservative options simply are not tried first. For musculoskeletal problems like joint pain, sprains, and strains, seeing a physical therapist before a surgeon can help keep patients out of the operating room and get them back to their daily lives sooner. Studies have shown that physical therapy is just as good - if not better - than surgery for a multitude of conditions, and it carries far less risk. We've compiled some research here as to the benefits of seeking physical therapy first for common orthopedic problems. 

Rotator Cuff Tears 

The rotator cuff is a group of muscles and tendons that surround the shoulder joint and provide strength and stability. When one of the rotator cuff muscles is frayed or damaged, it is considered a partial tear, whereas a complete tear is more severe and can actually pull the tendon from the attachment on the bone. Tears happen over time from normal wear and tear, or they can happen traumatically with a fall or strain. 

Small- to medium-sized tears typically respond quite well to physical therapy. A 2016 review of medical literature noted that conservative PT treatment for rotator cuff tears is effective in 73-80% of patients. While this efficacy rate depends on the age and medical history of the patient, the location of the tear, and the severity of the tear, more often than not surgery can be avoided (though in the case of a massive rotator cuff tear or a retracted tendon, the positive response to physical therapy may be reduced).

Meniscal Tears 

One of the most common knee injuries, meniscal tears are typically caused by an activity that twists the knee, and often occur when underlying osteoarthritis is present. An estimated 460,000 patients in the United States get surgery each year to fix tears in this C-shaped piece of cartilage, which acts like a cushion for the knee joint. 

Researchers are currently studying the effectiveness of surgery versus physical therapy in those patients with meniscal tears and knee arthritis. In a study of 351 patients who were 45 years and older with meniscal tears and osteoarthritis, half received physical therapy while the other half underwent surgery. The research did not find any significant differences after 6 months in those who received physical therapy alone and those who had surgery. Additionally, a 2017 literature review found that arthroscopic surgery for degenerative knee disease (including arthritis and meniscal tears) did not give lasting pain relief or improved function. Often, physical therapy is the optimal place to start to address this common knee injury.

Low Back Pain 

One type of back pain, called spinal stenosis, is a degenerative disease that causes narrowing of the space in the spinal canal. This narrowing creates pressure on spinal nerves and can become increasingly painful. Spinal stenosis is sometimes treated with surgery, but physical therapy often works just as well and comes with fewer unwanted complications than surgery, according to a study published in Annals of Internal Medicine in 2015. 

 Degenerative disk disease is also a common cause of back pain and has been studied extensively. Disk patients are sometimes treated with a surgical spinal fusion. However, a 2013 study found no major difference in outcomes between patients who had surgery for degenerative disk disease and those who chose physical therapy instead. 

Physical therapy can't fix every problem, and for some patients, surgery really is the best choice. However, the research continues to demonstrate that surgery is not a cure-all, and in fact is sometimes a very expensive and risky placebo. In many cases, physical therapy is the place to start - and for some, it's the only treatment necessary. 

 

References: 

Peter Edwards, Allan Wang. "Exercise Rehabilitation in the Non-Operative Management of Rotator Cuff Tears: A Review of the Literature". Pubmed Central (PMC), 2021.

"Surgery Versus Physical Therapy For A Meniscal Tear And Osteoarthritis". Vol 369, no. 7, 2013, pp. 683-683. Massachusetts Medical Society, doi:10.1056/nejmx130035. 

Siemieniuk, Reed A C et al. "Arthroscopic Surgery For Degenerative Knee Arthritis And Meniscal Tears: A Clinical Practice Guideline". BMJ, 2017, p. j1982. BMJ, doi:10.1136/bmj.j1982. 

Kuhn, John E. et al. "Effectiveness Of Physical Therapy In Treating Atraumatic Full-Thickness Rotator Cuff Tears: A Multicenter Prospective Cohort Study". Journal Of Shoulder And Elbow Surgery, vol 22, no. 10, 2013, pp. 1371-1379. Elsevier BV, doi:10.1016/j.jse.2013.01.026. 

Barrer, Steven J. "Surgery Versus Nonsurgical Treatment Of Lumbar Spinal Stenosis". Annals Of Internal Medicine, vol 163, no. 5, 2015, p. 396. American College Of Physicians, doi:10.7326/l15-5129.

Getting to the Point: All About Dry Needling

by Meg Crowley, PT

Though it seems like the newest kid on the block when it comes to physical therapy interventions, dry needling has actually been around since the 1940s as a treatment for pain and myofascial (muscle) trigger points. It utilizes very thin solid needles inserted into symptomatic tissue, primarily skin, muscle and connective tissue. When inserted, the needle creates a micro-lesion, which increases circulation, helps to normalize the inflammatory response, can cause a disruption in shortened tissues (trigger points), and provides input to the nervous system. These effects help to balance the environment within your body to promote healing with the end goal of reducing your pain.

While you may be envisioning the kinds of needles used for vaccinations, dry needling needles are actually extremely thin in diameter and flexible. This allows the needle to be pushed through the skin - instead of cutting the skin - which helps reduce discomfort upon insertion of the needle and makes it almost painless. Some patients do report feeling a dull ache, which is a common and positive response to needling. Other patients report feeling a muscle contraction: this is called a local twitch response, and is normal with needle insertion into pathological tissue. The technique for dry needling is a clean technique, with single-use sterile needles utilized to minimize risk of infection.

This may sound a little like acupuncture, but it is distinctly different: while acupuncture does use needles, its purpose is to change the path of Qi (or energy) along traditional Chinese meridians. Dry needling, on the other hand, is a modern, evidence-based intervention for the treatment of pain and movement dysfunction in common musculoskeletal conditions. All entry-level physical therapists receive extensive education in anatomy and the body’s movement systems, and in order to dry needle, physical therapists in the state of Illinois undergo postgraduate education and training specific to the application of dry needling, with emphasis on neuro-anatomy and how that impacts needle placement. 

So, how does it work? Well, since the body is a highly integrated system - with the nervous system, circulatory system and lymphatic system being primary connectors within the body - the insertion of the needle into tissue can have effects both locally and systemically. Locally, it can help improve circulation and reduce pain. This sets off a systemic chain reaction: the changes in muscle after needling, through the release of potential trigger points, can help improve movement patterns. Improved movement patterns lead to more efficient and effective movements. This in turn equates to less pain and improvement in your ability to perform the tasks you like to do on a regular basis.

As with any procedure, there are potential side effects. Many of these side effects are similar to what might occur after receiving any type of injection from a healthcare provider, with the most common being bruising and/or bleeding. The likelihood of bruising and bleeding is low, occurring in less than 15% of the cases. This is likely because of the small diameter of the needle used. Other adverse reactions that might occur less than 5% of the time include nausea, dizziness, drowsiness and worsening of symptoms, though again these are uncommon. In fact, multiple research studies have shown dry needling to be a very safe practice when performed by well-trained medical professionals.

Interested to see if dry needing can help alleviate your pain? We are now offering dry needling at our Illinois Center location.

Resources:

APTA Public Policy, Practice, and Professional Affairs Unit. (n.d). Description of dry needling in clinical practice: an educational resource paper. American Physical Therapy Association. http://www.apta.org/StateIssues/DryNeedling/ClinicalPracticeResourcePaper/.

Brady, S., McEvoy, J., Dommerholt, J., & Doody, C. (2014). Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. Journal of Manual & Manipulative Therapy, 22(3), 134-140.

McCutcheon, L., & Yelland, M. (2011). Iatrogenic pneumothorax: safety concerns when using acupuncture or dry needling in the thoracic region. Physical Therapy Reviews, 16(2), 127.

Sanders, N. (2020, Mar. 13-15).Pain management and sports rehabilitation: integrative dry needling foundation course. Integrative Dry Needling Institute.

Telehealth at Lakeshore Physical Therapy is Here!

In light of the recent health concerns regarding the COVID-19 pandemic, we have been working behind the scenes to quickly roll out a telehealth option for you. Here is what you need to know!

What is telehealth?  An online, web-based option to virtually meet with one of our experienced clinicians to receive evaluation and treatment for your musculoskeletal injuries/ conditions.  What can a physical therapist provide in a telehealth visit? There are many benefits to meeting virtually with your physical therapist! We can: Update your corrective exercises Teach you self-care techniques to promote tissue health Assist with posture modifications and work station set-up Provide post surgical monitoring Complete a functional movement assessment Provide an injury screening Continue to give you our individualized attention in a virtual setting Okay, I’m interested - tell me more! Due to some patient barriers to receiving in-person care, we have established an interactive solution to your physical therapy needs. We are utilizing the web-based platform Doxy (www.doxy.me) which does not require you to download anything or create a profile of any sort. Does my insurance cover this? We are working with major insurance carriers to properly bill and cover telehealth services. As this is a new and ever changing situation, this is still underway. For more information on your specific insurance benefits, please contact us directly.  So what payment options do I have? We are currently offering a competitive self-pay rate of $75 per visit for a quality one-on-one session with your physical therapist. Don’t forget, your HSA or FSA card can be used towards these visits! This sounds great! How do I schedule an appointment? To book your telehealth e-visit, please call one of our offices directly. Your pain can’t wait and neither should you!

Direct Access = Direct Improvement

by Sally Fansler, PT

Did you know that you can schedule an appointment with a physical therapist...without the need for a referral from your doctor?

As discussed in one of our previous blogs, Illinois is now a direct access state, which allows patients to attend physical therapy without a referral from a doctor. This access allows for greater autonomy for both patients and therapists in our state. Since this legislation is only a little over a year old, however, word travels slowly, and many of our patients are not aware of the choices they have when seeking medical care.  

Prior to this advancement in 2018, restrictions on direct access proved to delay the healing process for patients and increase medical expenses by requiring a separate consultation and often additional testing. Patients would often be delayed weeks in beginning their treatment due to the need to schedule an appointment with their primary care physician, and patients who did not have a primary care physician would have to navigate the process of finding someone and becoming a new patient. By making physical therapy more accessible to patients, direct access allows physical therapists to treat patients immediately, leading to more expedient improvement.

Furthermore, multiple research studies have agreed on the benefits of direct access. A study from Georgetown and Johns Hopkins University found that the total paid averaged $2236 for “physician referral” episodes of physical therapy as compared to $1004 for “direct access” episodes of physical therapy. Additionally, the physician referral episodes were 65% longer in duration than the direct access episodes. A similar study from the Journal of Health Services Research analyzed patients with low back pain. Those who saw a physical therapist at the first point of care had an 89% lower probability of having an opioid prescription and a 28% lower probability of having any advanced imaging services. The pattern is clear - lower cost, quicker improvement, and positive outcomes.

Direct access for physical therapy in Illinois has been a long time in the making, and has only been made possible through the expense, time, energy and effort on the part of physical therapists and physical therapy advocates throughout the U.S.to finally allow consumers (like you!) prompt access to physical therapy services.  We are confident that, with fewer barriers, our patients will choose P.T. first! 

Call to Action:

Spread the word!  

At Lakeshore Physical Therapy, we are honored when our patients exercise their right to direct access care from our experienced physical therapists that are fully invested in their progress.

Resources:

Denniger T. et al. (2017). The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry. Journal of Orthopaedic & Sports Physical Therapy, 2017, Volume:48 Issue:2 Pages:63-71 doi: 10.2519/jospt.2018.7423

Mitchell J. (1997). A Comparison of Resource Use and Cost in Direct Access Versus Physician Referral Episodes of Physical Therapy. Physical Therapy, Volume 77, Issue 1, 1 January 1997, Pages 10–18, doi.org/10.1093/pti/77.1.10

Frogner B. (2018). Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Services Research, 2018 Dec;53(6):4629-4646. doi: 10.1111/1475-6773.12984. Epub 2018 May 23.

Happy National Physical Therapy Month!

As the weather cools in the fall, it’s tempting to be less physically active. October is the perfect time to stay focused on healthy self-care because we’re celebrating National Physical Therapy Month! Find new ways to get your body moving. Whether you’ve felt intimidated by yoga, you’ve always wanted to play tennis, or you’re finally ready to sign up for that 5K race, this month may be the perfect time to push yourself just a little out of your comfort zone. Your physical therapists at Lakeshore Physical Therapy are here to support you! Choose more movement. Choose better health. Choose physical therapy.

Sciatica: One Pain, Many Causes

by Constance Taras, PT

Anyone who has ever experienced sciatica knows the feeling: a radiating pain or numbness that runs down the buttock, leg and even as far down as the calf and foot. So named because it is felt along the path of the sciatic nerve, sciatica is not a disorder in and of itself but rather a symptom that can be caused by many different pathologies including a herniated disc (Picture A), stenosis, SI dysfunction, piriformis spasm (Picture B), or core instability. Having the source of your pain be diagnosed is very important for proper treatment as not one size fits all!

         Picture A: Herniated disc                   Picture B: Piriformis spasm

The sciatic nerve is comprised of the nerves that come out of the lower lumbar spine (L4-S3 nerve roots), which group together, run through the buttock (most commonly through the piriformis muscle) and down the back of the leg all the way to the foot. Irritation to this nerve usually takes the form of tingling, numbness, or burning, but sciatica sufferers have also reported sharp or burning pain and weakness. 

For nerves to stay happy, they have to have enough of three main elements: movement, blood flow, and space. Addressing these factors help guide our treatment of nerve pain.

• Increasing Movement: Nerves don’t really stretch, but we can perform glides to slide them along their track and keep them from adhering to surrounding tissues.
• Increasing Blood Flow: Heat increases blood flow and is typically a good line of treatment for nerve injuries to promote healing. 
• Increasing Space: We want to ensure there aren’t any structures compressing the nerve such as a bulging disc, a muscle in spasm, or narrowed vertebral foramen (bony space where the nerve exits the spinal column). A variety of manual techniques and self-stretches and exercises may be prescribed to improve the space around the nerve.

In more chronic or extreme cases, irritation or compression of a nerve can cause weakness to the affected muscle as nerves also innervate (or give “electrical power” to) muscles. The muscles most commonly affected by sciatic nerve injury are the hamstrings (which bend the knee), anterior tibialis (which can result in foot drop), calf, and other ankle/foot muscles. Weakness in any of these groups can result in decreased balance, difficulty with stairs and prolonged walking, and feeling like your leg is going to give out on you.

Understanding where your pain is coming from is the first step to recovery – then having it properly treated by a physical therapist is the next best step. At Lakeshore Physical Therapy we treat these type of injuries and pathologies all of the time. We feel confident that we can identify the source of your sciatica and quickly get you pain-free!

Check out our recent Instagram post @lakeshorephysicaltherapy to see videos of some suggested exercises to treat your nerve pain!

Ice versus Heat: A Hot (or Cold) Topic

by Constance Taras, PT

One of the questions we most commonly field when patients have first sustained an injury is “Should I ice it, or would heat be better?” Both heat and ice are conservative, beneficial modalities, but to better understand the benefits of either, let’s first look at the physiological effects of each:
 

Typically, the more traditional approach is to apply ice to musculoskeletal injuries, but the type of musculoskeletal injury is important. For acute injuries that are swollen, warm, and painful (such as ankle sprains), ice can temporarily numb the area and decrease pain signals from the nerves, therefore decreasing pain. Ice also constricts the surrounding blood vessels so that less fluid and fewer cells arrive at the injured area. While this could theoretically slow down healing to the area as it does restrict the flow of healing mediator cells (leukocytes) to the area, it also means that less swelling is present. Less pressure on all the surrounding structures could mean less pain and improved range of motion.

However, what if we are dealing with a more chronic injury? Chronic injuries often suffer from decreased blood flow to the injured area, and as a result have a harder time healing. Application of heat, therefore, is the more beneficial modality, as it increases the rate that blood and repairing cells reach the injured site to improve the overall healing process. We also tend to recommend heat over ice in the case of a muscle in spasm or a tight muscle: the improved tissue extensibility provided by heat helps to relax shortened and tensed muscles in order to decrease spam and ultimately pain. Heat also allows improved stretching and increased range of motion, whereas ice could cause the muscle to tighten further, decreasing range of motion at a joint.

But an equally important factor to consider is how heat or ice makes you feel! If ice makes your pain worse or vice versa then it may not be the best option for you, even if clinically it makes more sense (unless it is contraindicated by other health conditions, such as diabetes, Raynaud’s disease or hypertension). If you are unsure what is the best modality for you and your specific injury, reach out to a Lakeshore physical therapist to help you build a customized plan!

References:

Malanga et. al. Mechanisms and efficacy of heat and cold therapies for musculoskelatal injury. Postgrad Med 2015; Early Online 1-9.

Thoracic Outlet Syndrome: A Pressing Matter

by Julia Glick, PT

 If you follow the NBA you have most likely heard that Markelle Fultz, the Philadelphia 76ers’ guard, has thoracic outlet syndrome (TOS). We most commonly hear of athletes from baseball developing this, but rarely basketball – in fact, basketball player Ben Uzoh wasn’t diagnosed until he retired, even though he had previously experienced TOS symptoms. It also took visits to more than 10 clinicians before Fultz was diagnosed with neurogenic TOS. But what does that mean and why was it so hard to diagnose? 

The thoracic outlet is the area between the first rib and collarbone, through which the majority of the nerves and arteries/veins that enter the arm pass. In TOS something in this space narrows and compromises either the nerves or vasculature (arteries/veins). A person with TOS usually has pain, temperature changes, or numbness/tingling at the neck, shoulder, arm, or hand.

Part of what makes it so difficult to diagnose is that there are no standard diagnostic criteria for TOS. There are also several presentations: neurogenic, vascular, and non-specific. With neurogenic TOS, the brachial plexus (nerves that pass through the thoracic outlet) are compressed and will usually cause pain and/or weakness. Features of vascular TOS tend to look more like coldness and numbness, as the arteries and veins are compressed. Regardless of presentation, these symptoms are often difficult to reproduce because they can change based on the position of the head, neck, shoulders and arms.

There are no specific causes for TOS, which often makes it even harder to diagnose. Past trauma or overuse, such as in overhead sports, could possibly increase the likelihood of developing TOS. Anatomically, someone is more at risk if they have an extra upper rib or have any type of tightness of fascia or muscle that decrease the amount of space of the thoracic outlet.

Presently, there are several treatment options for TOS: physical therapy, injection, and first rib removal surgery. In physical therapy, the goals are to restore full range of motion of the shoulder and neck, decrease any restrictions that are impinging on the nerves as they pass through the thoracic outlet, decreasing pain, and improving strength. Fultz has been attending physical therapy, and his agent has reported improvements: they hope he will return in the 2018-2019 season. Here’s hoping for a full recovery for Fultz! 

References: 

Baumann, M. (2018, December 4). What baseball can tell us about Markelle Fultz’s latest diagnosis. https://www.theringer.com/nba/2018/12/4/18126446/markelle-fultz-thoracic-outlet-syndrome 

Bell, S. (2018, December 10). What is thoracic outlet syndrome, and what does it mean for Markelle Fultz? http://www.espn.com/nba/story/_/id/25455660/what-thoracic-outlet-syndrome-does-mean-markelle-fultz

Povlsen B, Hansson T, Povlsen SD. Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD007218. DOI: 10.1002/14651858.CD007218.pub

Retrieved from: https://twitter.com/wojespn/status/1070074789409153024  

Retrieved from: https://twitter.com/ESPNNBA/status/1077668580706209792

Smith, J. (2018, December 4). Sixers announce Markelle Fultz out indefinitely, reveal plan for injury. https://sixerswire.usatoday.com/2018/12/04/sixers-markelle-fultz-out-indefinitely-shoulder-injury/ 

Wojnarowski, A. (2018, December 5). 76ers’ Markelle Fultz has thoracic outlet syndrome, to miss 3-6 weeks. http://www.espn.com/nba/story/_/id/25453907/markelle-fultz-philadelphia-76ers-expected-miss-3-6-weeks-shoulder-rehabilitation

Plantar Fasciitis: More Than Just a Footnote

by James Bansberg, DPT

Feet: so far away and often overlooked…until you wake up one morning and realize it’s impossible to place any weight through your foot. Feet are our foundation - our body’s connection with the earth - yet we place them in tight, uncomfortably angled, or worn down shoes, and refuse to maintain them the way we do other body parts.  Considering that plantar fasciitis is the leading cause of heel pain, and affects more than 2 million people in the US, it may be time to give this hard-working appendage a little more love.  

The plantar fascia is made up of thick fibrous bands of connective tissue that act like a cable between the heel and toes. These bands work hard, acting as shock absorbers, foot stabilizers, and arch supporters. Since we can be so unforgiving to our feet, there are multiple impairments that can lead to aggravation of the tissue. So what kind of risk factors should you be looking for in order to get to the root of the cause?

• Poor ankle and toe mobility
• Ramping up activity too quickly (marathon training!)
• Obesity
• Age (typically 40+)
• High or low arches
• Stiff/cramping calf muscles
• Prolonged daily standing on hard surface
• Improper footwear (worn, poor fitting, high heels, low support)

The presence of any of these risk factors can lead to plantar fasciitis, and many of us have more than one. Fortunately, there are just as many options to reduce risk: stretching and strengthening muscles that may be cramping or that don’t get much opportunity to be fully stretched often helps, as does rest. Proper shoe fitting (as well as replacing stressful footwear with more supportive options) can dramatically reduce risk, and if obesity is a factor, weight loss may help as well. Depending on the severity of pain, your doctor may recommend other options, such as night splinting.

If you have foot pain, however,evidence suggests that physical therapy will help you recover faster and cost you less than if you do not receive treatment. Experienced therapists at Lakeshore Physical Therapy will administer a comprehensive evaluation to determine impairments and utilize current evidence and proper treatment to help lower pain and improve function.  

Resources:

“Utilization of Physical Therapy Intervention Among Patients With Plantar Fasciitis in the United States” (J Orthop Sports Phys Ther 2017;47(2):49–55. doi:10.2519/jospt.2017.6999).

Tape on Me: Kinesiology Tape and Physical Therapy

by Jill McCormick, PT

If you’ve watched sporting events recently, you may have noticed professional athletes sporting cool-looking tape on their shoulders or knees. It’s not some obscure form of body modification – it’s kinesiology tape. Believe it or not, kinesiology tape has become so mainstream lately that you may have even seen someone standing next to you in line at the grocery store with this unique-looking application.

Unlike the old-school athletic tape, kinesiology tape has both stretch and memory. This allows for unlimited movement of the joint or limb while keeping it in place. It is designed to stay on for days at a time, even in the shower or pool. While you may remember first seeing it on the US Women’s Volleyball player Kerri Walsh, t’s not just for athletes or sports injuries. This tape is used in physical therapy to treat all kinds of pain and injuries, including shoulder tendonitis, hamstring strains, low back pain and running injuries.

Upon application, it lifts the skin, allowing for increased circulation and reducing inflammation. The recoil effect helps support muscles, ligaments, fascia and even bones. Furthermore, the sensory effect of the tape on the skin can reduce pain signals to the brain, bring the brain’s attention to muscles that are atrophied or underutilized, and calm a muscle that is overactive or in spasm. Seemingly like magic, patients often see an improvement in range of motion and decreased pain immediately!

In summary, kinesiology tape can be used on sports and non-sports injuries alike and it often helps reduce pain and increase range of motion on the spot. While it isn’t magic, it certainly can seem like it and it can be a very valuable and effective adjunct to your physical therapy program. If you are unsure about whether kinesiology taping is a good option for treating the injury you have, Lakeshore Physical Therapy has therapists with expertise in the taping technique and can provide recommendations to help you to heal properly.

Swimmer's Shoulder: What You Should Know

by Stephanie Korso, PT

Swimming is a phenomenal way to improve cardiovascular fitness, burn lots of calories, strengthen muscles and prevent disease. As a non-contact sport, there is little risk for acute and catastrophic injuries, but there is still risk for injury. Prevention, early recognition and early treatment are key to managing swimming injuries and remaining active.

The most common swimming injury is swimmer's shoulder, which refers to any shoulder pain related to swimming. Up to 90% of swimming injuries involve the shoulder, and as many as 73% of swimmers may report shoulder pain during their career. The repetitive nature of swimming contributes to overuse and predisposes swimmers to shoulder injury.

Although swimmer's shoulder can involve any shoulder dysfunction, such as tendinosis or impingement syndrome, shoulder instability is the most common. This is because the same factors that improve swimming performance also contribute to shoulder instability:

Increased Shoulder Range of Motion
Increased shoulder range of motion helps reduce drag and allows for greater stroke length, both of which contribute to increased swimming speed. However, increased range of motion also contributes to increased ligament laxity and increased strain on rotator cuff muscles, which contributes to decreased stability.

Increased Shoulder Adduction and Internal Rotation Strength
Up to 90% of forward propulsion in swimming comes from the upper body. The pectoralis major and latissimus dorsi muscles, responsible for shoulder adduction and internal rotation, are the primary muscles that create the propulsive force needed in swimming. Increased strength in these muscles contributes to increased swimming speed, but it also leads to muscle imbalance and further instability.

Prolonged, Fatiguing Shoulder-Intensive Training
An experienced swimmer knows that swimming involves both shoulder strength and endurance. Training involves long work-outs that fatigue muscles. As rotator cuff and scapular muscles fatigue, shoulder instability increases.

The primary goals in management of swimmer's shoulder are to reduce inflammation, increase stability and return the athlete to full activity as soon as possible. Initially, the athlete will need to modify activity so that no pain is experienced. During this time, the athlete will implement exercises to decrease muscle imbalances, improve rotator cuff and scapular strength, and improve muscle endurance. The athlete may then gradually increase activity as pain decreases. Physical therapy is often helpful not only to guide progressions of strength exercises, but to also improve spine mobility and help release overworked pectoralis major and latissimus dorsi muscles.

As the saying goes, prevention is better than the cure. Therefore, incorporating exercises to strengthen the rotator cuff and scapular muscles into training regimens prior to onset of pain is optimal.

References:
Weldon EJ III, Richardson AB. Upper extremity overuse injuries in swimming. Clinical Sports Med. 2001; 20(3), 423-438.

Weiss Kelly A. Non-contact sports: Running, swimming, and dance - identifying common injuries. Pediatric Annals. 2010; 39(5), 279-285.

Khodaee M, Edelman GT, Spittler J, et al. Medical care for swimmers. Sports Med. 2016; 2(27).