Humans (and proto-humans) may have been running long distances for the last two million years, but swimming far is a modern pursuit. Shoulders often fatigue and become injured when put through the demands of long-distance open water swimming, but can we blame them? How long have humans been swimming this over-head “freestyle” anyway? Shoulder problems from swimming are often attributed to bad form; what about fatigue and anatomical abnormalities? Arthroscopic surgery is minimally invasive, quick, and leaves tiny rice-sized scars. But all surgery comes with very real risks, even for the young and fit (read: those post-op complications couldda killed me!).
Endurance swimming was not instrumental in the evolution of the human body form…
If our distant ancestors swam at all, they most likely did not swim the front crawl, and they certainly didn’t make a habit of swimming marathon distances. An early hunter throwing rocks and spears, in a motion very similar to a single stroke of freestyle, utilized the remarkable range of motion of the human shoulder joint, but he or she would have had no good reason to repeat that motion thousands upon thousands of times in succession. And while there are ridiculously charismatic folks who defend a controversial “aquatic ape theory” (watch the talk), positing that humans went through a semi-aquatic stage in their evolutionary history, even they make no mention of distance swimming or an over-arm stroke. Simply put, long-distance “marathon” swimming (10K or farther) is a very modern pursuit; most identify its beginnings at Captain Web’s unprecedented, beef tea and brandy fueled, swim from Dover to Calais on August 25th,1875. He swam the 21 miles breast stroke in 21 hours and 45 minutes. Compare that to our species’ long history as distance runners, a trendy topic since the 2009 publication of Christopher McDougall’s Born to Run, and recently the subject of much research. This bit, from a 2004 article in Nature, caught my attention: “fossil evidence suggests that endurance running… originating about 2 million years ago… may have been instrumental in the evolution of the human body form” (source). So while the human body may be built, quite literally, for endurance running, we were in no way built for endurance swimming.
Considering our species’ relatively late foray into endurance swimming, and hence our bodies’ lack of adaptation to the demands of the sport, it is no surprise that marathon swimmers commonly experience shoulder pain when engaging, as they so often do, in swims that involve hours upon hours of repetitive shoulder rotation. (A typical English Channel crossing time is something like 10-14 hours, and some folks even touch down in France only to swim back to Dover.) Of course, that’s no reason not to do marathon swimming—humans do all sorts of things our ancestors surely never even dreamed of—but it does help us to understand why so many shoulders don’t hold up to what long distance swimmers put them through. We are just not built for it.
Studying Frogs – A Very Abridged History of Swimming
Our species’ short history of swimming is surprisingly fascinating. While not marathon swimmers, Ancient Egyptian cave paintings depicted swimming people, and both the Bible and Homer’s Odyssey reference swimming in their stories. As early as the Middle Ages, whole books were written about swimming, although the focus of these were often on the ability to “not drown” (source). As recently as 1850, when Matthew Web was a boy learning to swim (something most did only under doctor’s orders, as a cure for various ailments) swimming instruction was limited to the vague: “Imitate the movements of a frog.” Aspiring young swimmers were instructed to keep frogs in tanks so that they could study them (source). I think that little factoid is my favorite.
The front crawl, or “freestyle,” the stroke nearly all marathon swimmers use today, is a particularly modern development in the history of swimming. It was in 1902 that the Australian swimmer Richard Cavill “was the first to swim with an up-and-down kick and alternating over-arm recoveries.” We called Cavill’s stroke the “Australian crawl,” and from it evolved modern freestyle (source). When Gertrude Ederle was training to become to first woman to swim across the English Channel in the 1910s and 20s, the new stroke was just hitting the swim clubs in NYC. And while the stroke has evolved, and has been continuously perfected by competitive swimmers over the last century, the majority of swimmers continue to use it for the relatively short distances of pool races (50-1650 yards).
Shoulder Season 2011
Many thousands of competitive swimmers have been instrumental in the evolution of freestyle over the last 100 years. (The stroke’s development is seen clearly in the increasingly faster race times over the years.) However, the marathon swimming community, although larger than it has ever been, has always been a small crowd, and so it could be argued that an open-water, endurance version of the stroke just hasn’t evolved yet in the same way.
It is not uncommon for excellent swimmers to suffer from shoulder issues when attempting long swims. This past fall, when Diana Nyad attempted a record-breaking 103-mile swim from Cuba to Florida, and much of the American public was made newly aware of distance swimming, she persevered through man-of-war stings and rough conditions, but had to throw in the towel due to a combination of asthma and shoulder pain: “I had severe pain in my right shoulder that was so excruciating that every stroke I took from the third hour all the way through 30, I just winced every time” (Source).
Marathon swimmer and blogger Evan Morrison (www.freshwaterswimmer.com) experiences shoulder fatigue which he attributes to overuse, not actual injury within the joint. He explains that shoulder fatigue “was the limiting factor in all my big swims this year – Tampa, MIMS, Catalina, and Ederle…The only thing holding me back was shoulder pain.”
I started experiencing shoulder pain in the fall of 2010, about the same time that I signed up for the 2011 10-mile Kingdom swim and started upping my weekly yardage. I got in the habit of icing my shoulders at night, and when the open water season began, I just kept swimming through the pain. I assumed from the beginning that my issue must be due to biomechanics, and so I asked my coach to scrutinize my stroke and give me pointers. (While I am not the fastest swimmer in a pack, I have always had pretty good form; I breathe bilaterally, rotate from my core, have a strong, steady kick and a smooth relaxed stroke etc.) Although I pushed him to correct something, he didn’t find anything obviously wrong to correct in my stroke. When, by August 2011, the pain had gotten significantly worse, I sent out an email requesting advice from my local open water swimming community, the CIBBOWS:
On Mon, Aug 8, 2011 at 11:31 AM, Caitlin Rosen wrote:
There is something wrong with my stroke. It works well for about 3 hours, and then my left shoulder starts hurting. After a long swim in which I have kept swimming with that pain for more hours (for example: 6 hour Malta swim, the Kingdom 10 mile, the Swim Across Long Island sound- 25K two-person relay), my left arm goes dead– zero strength in it. Super painful, and I have to use my right arm to lift my left arm up and around. This lasts for a few days, then I get the strength back.
Please advise if you can. I’m looking for:
1.) Favorite places to get stroke fine-tuning advice (with video analysis?)
2.) a sports medicine doc who really knows swimming and swimmers issues
3.) physical therapist who really knows swimming and swimmers issues
4.) a sports massage person who knows swimming… etc.
The problem with advice on something like a bum shoulder is that it is easy to feel like you have access to way too much of it. If I thought asking a bunch of open water swimmers would narrow the results, I was wrong. I received an enormous number of helpful replies suggesting therapies, doctors, and stroke mechanics from the CIBBOWS. Of course, with the internet, I also had access to endless articles and blog posts on swimming-related shoulder issues. I collected much of the advice on shoulders that I received from fellow swimmers, as well as some of the advice that I found, and put together a separate post: on the Shoulders of Swimmers — Boatloads of Advice. As is instantly clear, there are lots of ways to think about and approach the same problem.
Here is what I ended up doing: I saw a recommended sports medicine doctor who ordered MRIs of my shoulders, which showed labral tears. He suggested seeing a specialist/surgeon. I went to a very highly recommended shoulder surgeon, Dr. Jonathan Glashow, and he explained that I didn’t need to have the surgery right then, but that if I wanted to keep swimming long distances, I probably would. I wanted to swim longer distances, and I didn’t want to postpone the recovery process (I’d already been out of the water for two months), so I decided to go ahead with arthroscopic surgery on my left shoulder in October. The operation revealed something unexpected. Glashow reported finding a very upset rotator cuff (remember that I had not been swimming for two months by the time he was looking inside) and a large subacromial bone spur causing it. In post-op discussions he explained that with each overhead rotation of my arm, the bone spur in my shoulder joint was tearing into my rotator cuff, and it wouldn’t have mattered how I changed my stroke, I couldn’t have avoided the damage. His assistant Chris used the metaphor of a rope (rotator cuff) being rubbed back and forth across a pointed stone (the bone spur). I asked how I got the bone spur– still thinking it must be a problem with my stroke— and he said (right in front of my mom) that I most likely came from the factory that way. So instead of stitching up tears, Glashow filed off the bone spur, explaining that with the offending bit gone, the shoulder should heal on its own. I’ve been in physical therapy for a few months (with my excellent PT Luciano at a NYSports Med in Union Square) and just last week I began using my arms again to swim.
So while stroke mechanics may not have been the cause of my shoulder problems after all, I am being hyper-vigilant as I rebuild my stroke, to do so with intention at every level and with extra attention to detail. (What exactly are the characteristics of a perfect open water long-distance stroke? Deciding on my answer to that is what keeps me up nights these days. Advice is often inconsistent. See on The Shoulders of Swimmers — Boatloads of Advice) I am also working with my PT to strengthen the muscles that support the shoulder joint, and will continue diligently with dry-land exercises as long as I remain a swimmer. In February, I travel to Egypt to swim in the Red Sea off the Sinai Peninsula with SwimTrek. The water will be warmer and the swims much shorter than my training with SwimTrek last year in Malta, and so it should be a good opportunity to test out my bone-spur-free shoulder, and get back in the game.
Whoops! Post-op Complications — My Pulmonary Embolisms
My operation went perfectly. I needed minimal pain-meds afterwards. My scars are tiny. But, unfortunately, shit happens. Surgery, no matter how world-renowned the surgeon or healthy the patient, is a risky activity. About two weeks after my surgery, I started to feel pain around my left bicep, and figured it was a muscular pain associated with my shoulder. Then I started having a little trouble breathing, which I thought was also muscular. Perhaps, I thought, I had slept funny and pulled something or was holding myself funny to compensate for the injured arm. An evening chat with my surgeon, followed by a day of testing with cardiologist Dr. Adam Rosenbluth, revealed that I had experienced two pulmonary embolisms (blood clots to the lungs). Rosenbluth had ordered a very comprehensive set of tests because the likelihood that I had actually had a pulmonary embolism originating in my arm was so slim; we needed to rule out everything else first. In fact, when I met Dr. Rosenbluth he described the possibility of a blood clot as both the “worst case scenario,” and so unlikely that it was “unheard-of.” Pulmonary embolisms may not be uncommon after knee surgery, but after shoulder surgery, “unheard-of.”
Through all of the testing, I learned that my heart is extremely strong, my blood pressure very healthy, and my lung capacity above average; in other words, I am healthy. Also relevant, as far as blood clots are concerned, I do not smoke and never have. But, as my luck would have it, clots that had originated on my left side, below the surgery, broke off, traveled up my arm, through my heart, and lodged themselves in my right lung. The first landed up high, and made the very end of each breath challenging. The second (occurring about a day later), landed much lower, and caused significant pain in the middle of every breath. Only by holding my breath did I experience any relief. Once diagnosed and medicated (with Coumadin, as well as 2x/day self injections of Lovenox) the pain subsided and I mainly just felt exhausted. I was able to stop the injections about a week later, but I’ll be on the Coumadin for 6 months.