The shoulder that does not keep up with the sport

The shoulder is the most mobile joint in the human body — and also the most vulnerable to repetitive overload. When a swimmer feels pain on the pull, a volleyball player on the spike, or a CrossFit practitioner on the overhead press, what is generally happening is a failure in the kinetic chain that should protect the joint during overhead movements.

"Swimmer's shoulder" is the classic example: with each training session, a competitive swimmer performs hundreds of strokes with the shoulder in flexion and internal rotation. If the scapula does not adequately stabilize the humerus in this range, the subacromial space narrows and the rotator cuff tendons are compressed — leading to tendinopathy and impingement. But what frequently goes unnoticed is the role of trigger points: the infraspinatus and subscapularis with trigger points alter glenohumeral mechanics and perpetuate impingement, even when tendon inflammation is treated. The relationship with sharp shoulder pain when lifting the arm and stiff shoulder that does not lift is direct.

Mechanism of shoulder pain in overhead activities

  1. Repetitive supraspinatus overload

    The supraspinatus tendon is compressed between the humerus and the acromion during shoulder abduction and flexion above 90°. In repetitive activities (swimming, volleyball, crossfit), this compression generates cumulative tendon microinjury — rotator cuff tendinopathy.

  2. Infraspinatus: the most common shoulder trigger point

    The infraspinatus — external rotator of the humerus — is the rotator cuff muscle that most frequently develops trigger points. When hypertonic, it alters the centering of the humeral head in the glenoid, favoring superior translation and reducing the subacromial space. Dry needling of the infraspinatus is frequently the most impactful intervention.

  3. Subscapularis and restricted internal rotation

    The subscapularis, on the anterior aspect of the scapula, is the largest rotator cuff muscle. Trigger points in it restrict passive external rotation of the shoulder and alter the scapulohumeral rhythm. In swimming, hand entry into the water requires wide internal rotation — a tense subscapularis overloads the supraspinatus to compensate.

  4. Serratus anterior weakness

    The serratus anterior fixes the scapula to the thoracic wall and rotates it superiorly during arm elevation. When weak or with trigger points, the scapula "wings out" (winged scapula) and does not keep up with the humerus, narrowing the subacromial space and aggravating impingement.

  5. Pain-weakness-compensation cycle

    Shoulder pain leads to reflex inhibition of the rotator cuff, which generates compensatory biomechanical alteration (excessive use of deltoid and upper trapezius). This compensation perpetuates impingement and activates new trigger points — expanding pain and dysfunction.

Data on shoulder pain in overhead athletes

40–91%
OF COMPETITIVE SWIMMERS
report shoulder pain at some point in their career — "swimmer's shoulder" is the most prevalent injury in the sport
36%
OF CROSSFIT PRACTITIONERS
develop shoulder pain related to overhead movements — kipping pull-ups and overhead press are the biggest culprits
85%
OF PAINFUL SHOULDERS
in overhead athletes present palpable trigger points in the infraspinatus — the muscle most affected in sports shoulder pain
75%
RETURN TO SPORT
pain-free after combined treatment of dry needling of the rotator cuff, scapular stabilization, and correction of the sports gesture

Recognizing sports shoulder pain

Critérios clínicos
08 itens

Swimmer's shoulder / overhead shoulder — typical pattern

  1. 01

    Pain on the anterior or lateral aspect of the shoulder during the sports gesture (stroke, spike, press)

  2. 02

    Painful arc: between 60° and 120° of abduction (sign of impingement)

  3. 03

    Pain that progressively worsens during training and improves with rest

  4. 04

    Weakness in lifting the arm overhead or holding objects above the head

  5. 05

    Clicks or crepitus in the shoulder during wide movements

  6. 06

    Night pain when lying on the affected shoulder

  7. 07

    Gradual loss of sports performance (shorter stroke, weaker serve)

  8. 08

    Pain referred to the deltoid insertion or lateral aspect of the arm

Myths and facts about sports shoulder pain

Myth vs. Fact

MYTH

Shoulder pain when swimming means it is time to stop the sport

FACT

In most cases, it is not necessary to abandon the sport. Treatment of trigger points in the rotator cuff and correction of scapular dyskinesis allow return to sport without pain. Temporary interruption may be necessary to control acute inflammation, but the goal is always functional return with optimized biomechanics.

MYTH

MRI with supraspinatus tendinopathy always requires surgery

FACT

Tendinopathy (degenerative/inflammatory process of the tendon) is very different from complete rupture. Most rotator cuff tendinopathies respond to conservative treatment: dry needling, eccentric strengthening, and biomechanical correction. Even partial tears can be conservatively treated in many cases. Surgery is indicated for symptomatic complete tears or prolonged failure in conservative treatment.

MYTH

Strengthening the deltoid protects the shoulder in overhead activities

FACT

Strengthening the deltoid without stabilizing the scapula and the rotator cuff is counterproductive. The deltoid pulls the humerus upward, while the rotator cuff centralizes it in the glenoid. If the cuff is weak and the deltoid is strong, superior translation of the humerus increases — aggravating impingement. The focus should be on the stabilizers: infraspinatus, subscapularis, serratus anterior, and lower trapezius.

The infraspinatus: the muscle that changes everything

Treatment protocol

Biomechanical assessment of the shoulder
1st visit

Special tests: Neer (impingement), Hawkins (impingement), empty can (supraspinatus), lift-off (subscapularis), resisted external rotation test (infraspinatus). Assessment of scapular dyskinesis (dynamic observation of the scapula during flexion). Palpation of the infraspinatus, subscapularis, serratus anterior for trigger points.

Dry needling of the rotator cuff
Sessions 1–4

Needling of the infraspinatus (infraspinous fossa — direct and safe access). Dry needling of the subscapularis when indicated (access through the axillary border of the scapula). Needling of the supraspinatus (supraspinous fossa). 2 Hz electroacupuncture in the infraspinatus for deep analgesia and muscle relaxation.

Scapular stabilization
Sessions 3–6

Activation of the serratus anterior (wall slides, serratus punch). Strengthening of the lower trapezius (prone Y). External rotation exercises with elastic for the infraspinatus. Scapular control training in open and closed kinetic chain. Gradual load progression.

Return to sport with corrected biomechanics
Sessions 7–10

Analysis of the sports gesture (stroke in swimming, spike in volleyball, press in crossfit). Correction of compensatory patterns. Gradual return to training volume: starting with 50% of the usual volume, 10% progression per week. Monitoring: pain above 3/10 during the sports gesture indicates the need for regression.

Clinical pearl: the modified painful arc test

Scientific evidence

Frequently asked questions

FREQUENTLY ASKED QUESTIONS · 04

Frequently Asked Questions

It depends on the intensity of the pain. If the pain is mild (below 3/10) and only occurs at the end of training, it is possible to maintain swimming with reduced volume while treatment is performed. If pain occurs from the start and compromises stroke technique, it is recommended to temporarily replace it with exercises that do not overload the shoulder (such as running or cycling) until clinical improvement.

The infraspinatus is accessible on the posterior aspect of the scapula and needling is well tolerated. The twitch response (involuntary muscle contraction) is expected and may cause a brief twinge that reproduces the patient’s familiar pain. After the session, there may be local discomfort for 24–48 hours — similar to mild "post-workout pain". The benefit outweighs the transient discomfort.

Kinesio tape can offer proprioceptive feedback and light support to the scapula during activity, but the evidence for pain relief is limited. It works best as a complement — not as the main treatment. The pillars of treatment remain deactivation of trigger points and strengthening of the scapular stabilizers.

With combined treatment (dry needling + scapular stabilization + biomechanical correction), most recreational athletes return to sport without pain in 4–8 weeks. Competitive athletes with greater training volume may take 8–12 weeks for complete return. The return criterion is: complete sports gesture without pain and without visible biomechanical compensation.