Updated: December 13, 2018
As I mentioned in my August 19 Swim to the Moon 10K post, a month before the swim I was experiencing pain that a physical therapist believed was tendinopathy of the pectoralis minor, commonly referred to as “bench‐presser’s shoulder”. Activities that involve motion of the scapula, like bench‐pressing, swimming and push‐ups, can theoretically result in overuse of this muscle, especially if there’s poor technique or a rapid increase in training load, frequency and/or duration. Training for a 10K (6.2 miles) swim might seem a logical path to overuse of the shoulder and pec muscles, but I’ve been doing long distance swimming since 2012 without developing this problem. I went along with his recommendations, but was doubtful.
The reason I didn’t believe swimming was the sole reason was because I’ve worked with a great swim coach for the past 6 years, Anne Wilson of Camelback Coaching. She teaches the Total Immersion Swimming method and has expertise in biomechanics. With her guidance, I’ve worked hard to develop a smooth and efficient technique for long distance swimming, and I followed a structured training program that gradually increased distance.
By July of this year, I was five months into training for Swim To The Moon in Michigan. On July 8, I completed a 5 mile swim at Parker Canyon Lake (felt great after), and then did a 5 mile trail hike around the lake picking up trash, which I carried in bags for several miles. I was aware of some shoulder/neck strain at the time but I didn’t think that much about it. Five days later I did a 2 mile lake swim followed by a 2 mile trail run. The next day I had some pain in my right pec, but I was able to manage the pain with stretching and using a foam roller over the next several weeks. I did my longest open water swim of the year on July 27 — 6.4 miles. The following week the pain got worse, and was most noticeable in the mornings. In addition to swimming I was also cycling, running, and doing strength work and yoga. Since the pain never got worse while I was swimming, it was hard to know specifically what was causing it.
After a month of intermittent pain, I visited my primary care doctor who didn’t find anything obviously wrong (shoulder range of motion and strength were normal, and no external signs of inflammation). An X-ray of my chest and shoulder also didn’t show any problems. In early August, I started going to a physical therapist who I had worked with in the past. He believed that the issue was tendinopathy of the pectoralis minor, caused by “overuse” (he targeted swimming as the main contributing factor). He gave me exercises that focused on strengthening my lats, which I did every day over the 2 remaining weeks before Swim To The Moon.
I constantly had some degree of pain, and after sitting mostly motionless during a five hour flight to Michigan it was much worse. The day before the race I attended a course preview and did a short swim, but the pain in my left pec had me seriously worried about being able to complete 6.2 miles. That night I had a long talk with my brother who’s a doctor. Based on my symptoms and history, he assured me that I would probably be OK (although we discussed worst case scenarios). I took some Advil and got about 5 hours of sleep. To my great surprise, I was remarkably pain free on race day! Sadly, that was my only pain free day for the next six weeks.
When I returned home, I resumed going to the physical therapist, who gave me a more aggressive exercise program, as well as doing trigger point release therapy. He also suggested that I stop swimming and running for several weeks in an attempt to bring the inflammation under control. I followed his advice and stuck with his daily exercise program. However, after a month, the pain was getting worse instead of better. On September 28, given my lack of progress, the physical therapist suggested I see an orthopaedist, which I was reluctant to do given a bad previous experience. (I developed severe back pain in 2002 due to a protuding disc in my L5 S1, and an orthopaedist said there was nothing he could do until it got bad enough for surgery. Fortunately, I found a fantastic exercise physiologist, Rob Hughes, who taught me the McKenzie Method, which relieved the pain in a short amount of time!)
I needed to find another solution – the chronic pain was becoming very depressing. The location of the pain varied (left and right pec minor and major, and subclavical) but was always present to some degree. My first step was to visit a rolfer who I’ve known for 10 years. In addition to having tight neck muscles, she noticed that I had lost some of my natural thoracic and cervical curve. Next, I called Rob Hughes who now lives in Florida. He suspected an isssue with my neck mechanics and posture, but without seeing me was unable to help further. I also talked with a friend who is a yoga teacher and a physical therapist. She recommended that I see someone that she works with at ATI Physical Therapy. I started seeing Matt Sparrow the second week of October.
Matt immediately ruled out tendinopathy and had me stop doing the exercises the other PT had given me. In the first session he discovered that I had limited range of motion with cervical neck extension, reinforcing what Rob suspected, and confirming what my rolfer had found – that I had lost some of my natural thoracic and cervical curve. Muscles in my neck – sternocleidomastoid and scalenes – were also extremely tight. With a combination of body work and exercises to both strengthen and relax muscles in my neck and back, I started making progress and gradually was able to resume exercising. I even did 3 half marathons in October: 13.6 miles of the Arizona Trail on October 6, the Lake Powell Half Marathon on October 20, and 13.6 miles of trail in Oracle State Park. By the end of October I was almost pain free. I resumed cycling, yoga and very short, gentle pool sessions of swimming. Of these, the only thing that seemed to increase the pain was swimming, and usually by the next morning rather than during. I was baffled. While Matt could suggest some possible contributing factors, including my mild case of scoliosis, he wasn’t sure.
I started looking for another reason. What was unique to my swimming that could cause pain in the pec minor/major, sternum and neck, and even occasional tingling in my fingers after a long endurance swim? I had a session with my swim coach at the end of September and she thought my technique still looked good. Could it possibly be caused by my swimsuit? I was intrigued by articles on thoracic outlet syndrome, claudication, and costoclavicular compression. Many, but not all, of the symptoms applied to me. Thoracic outlet syndrome is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit, with signs and symptoms manifesting in the shoulders, neck, arms and hands. It’s typically a repetitive stress injury – athletes who frequently raise their arms above the head (such as swimmers) are among those who may develop TOS. Claudication is pain caused by too little blood flow, usually during exercise. It usually affects the blood vessels in the legs but it can also occur in the arms. Costoclavicular compression is the result of a scissoring action of the clavicle against the first rib that narrows the costoclavicular passage and shears the neurovascular bundle. The first rib elevates toward/against the clavicle. Tight anterior and middle scalenes and subclavius can also cause this to occur, as well as scoliosis. Very often this type of compression is found in women: tight, narrow brassiere straps supporting heavy breasts cut into the soft tissues around the shoulders and exert direct downward pressure on the clavicles. It also can be aggravated by work and exercise, particularly when carrying heavy objects. In the past year or so I started wearing swimsuits a size smaller than in previous years, and while I liked the slimmer fit around my torso, the straps were tighter than I was used to. I hadn’t considered that it could be a problem until after more than 300 miles of swimming in the tighter suits.
On November 9, I decided to experiment by doing an open water swim at Patagonia Lake State Park wearing a sleeveless wetsuit that doesn’t restrict arm movement, and dropping my swimsuit straps off of my shoulders. I did everything I could to avoid any downward pressure on my clavicles or any compression under my armpits. I swam a mile with only a couple of short breaks (longest distance I’ve done in over 2 months), and then did my cervical neck protraction/extension exercises afterwards. I didn’t have any pain before, during or after the swim, and the next morning I was still pain free! I had the same result several days later in a pool swim, wearing a swimsuit in a larger size with wider straps.
Conclusion? I believe that all of Matt Sparrow’s finding are accurate and there’s no doubt that I’ve benefited from the exercises and body work. However, Matt agrees that the tight swimsuits might have also contributed to the pain. I was discharged from physically therapy today, November 13! Hopefully, as long as I continue to be mindful of my neck and upper musculoskeletal issues, and follow Matt’s recommendations, I’ll continue to be pain free!
December 13 update:
I’ve continued doing my PT exercises daily, and have now resumed all my normal activities: swimming, cycling, yoga, hiking, running, and trail maintenance at Oracle State Park.
I had a great swim at my local pool today, Oro Valley Aquatic Center – best I’ve felt since June! I was tempted to keep going (I’m not good at moderation), but I’ve vowed to gradually build back up to my previous times and distances to avoid future setbacks.