If shoulder pain persists beyond two weeks despite a period of rest, if the pain is waking you at night, if you have noticed significant weakness in your arm, if you have any numbness or tingling in your fingers, if you have felt your shoulder come out of its socket, or the pain cannot be relieved by the judicious application of ice, it is time to see your sports medicine physician.

Compared to other sports, swimming is relatively safe. However, injuries occur and when they do, they can interfere with training as well as competing.

One of the most common problems seen in swimmers of all levels is shoulder pain. Probably all elite swimmers have had some shoulder pain at one time or another which has kept them out of the water. What causes shoulder pain, what can be done to prevent it, and how should it be treated?

Shoulder pain probably occurs because of the repetitive arm movements in swimming. Compared to a professional baseball or tennis player, who may go through 1,000 arm revolutions per week, a competitive swimmer may go through as many as 16,000 revolutions per week. Anything done that often is bound to cause problems.

Most swimmers develop very heavy upper body musculature, particularly in the front of the shoulders, and very weak musculature in the back. This gives most of them a stooped forward posture. One of the things that make swimmers susceptible to shoulder pain is the forward-placed position of the shoulder blades on the chest. Any attempt to treat or correct shoulder pain must also focus on proper posture and proper development of the back shoulder muscles.

Shoulder pain is almost always associated with some sort of training error. "Too much, too fast" is usually the cause. It was once popular to use paddles and a pull buoy for training, but some swimmers have found that the incidence of shoulder pain increased when these training aids were used. Now they are used in moderation, if at all.

Before discussing the treatment of shoulder pain, we have to know exactly what the cause is in each case. Certain diagnoses tend to be related to age. For example, in a swimmer older than 40, pain that radiates up into the neck or down the arm may be related to the cervical spine. If pain is down the left arm and radiates up into the jaw and occurs with exercise, then it could be related to the heart. Pain on the top of the shoulder is more likely related to the acromioclavicular joint and pain along the side of the shoulder may be related to the rotator cuff.

In younger swimmers, pain in the back of the shoulder is more typical of an instability problem while pain in the front and side of the shoulder more commonly occurs with a tendonitis problem.

The first response to shoulder pain is to rest until the pain goes away. This may not mean stopping training but rather altering it to the point where pain does not occur. The most important thing is that the pain goes away and the shoulder remains flexible.

People ask whether nonsteroidial anti-inflammatory agents are beneficial. This is a controversial question. There is some indication that nonsteroidial anti-inflammatory agents actually interfere with tendon healing. Proper nutrition — a good, balanced diet — is one of the best ways to repair injury.

Once pain is gone, a rehabilitation process begins, which involves not only the shoulder muscles but also the shoulder blade stabilizers. These muscles, which are important in the recovery phase of the arms during swimming, are rehabilitated.

All exercises should be done below the level of the shoulder with very light weights and high repetitions. Strengthening of the deltoid muscles as well as the supra and infrasinatus muscles is very important to rehabilitating the shoulder.

The third phase is to return to swimming quickly, but within the limits of the pain. One training aid that can be helpful is the use of fins. These allow the body to assume a higher position in the water and take some of the stress off of the shoulders. There is evidence that circulation to the rotator cuff is disturbed when arms are held straight in front, like when using a kickboard. Try kicking without a board on your side.

Returning to swimming should not create pain. Even if it means just a few laps to start, it is important to build up your distance gradually. Use this rule of thumb: Do not increase either speed or distance more than 10 percent per week. Do not increase both speed and distance at the same time.

The warm-up and cool-down portions of any workout are essential. It has been said that 10 percent of a workout (or 10 percent of the distance) should be spent either warming up or cooling sown. Some trainers recommend that swimmers spend more like 20 percent of their workout warming up and 20 percent cooling down.

If shoulder pain persists beyond two weeks despite a period of rest, if the pain is waking you at night, if you have noticed significant weakness in your arm, if you have any numbness or tingling in your fingers, if you have felt your shoulder come out of its socket, or the pain cannot be relieved by the judicious application of ice, it is time to see your sports medicine physician.

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