












































CLINICAL OUTCOMES RESEARCH 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 
 

Range of Motion Changes in Female Elite Swimmers Throughout a 
Competitive Season  
McCall E Christian, DAT, LAT, ATC1 and Lindsey E Eberman, PhD, LAT, ATC2 
1Missouri State University, Springfield, MO; 2Indiana State University, Terre Haute, IN  
 

 
ABSTRACT 

Upper extremity injuries are the most common injury in 
swimming athletes specifically in the collegiate setting. 
Females in particular, are more likely to suffer these injuries 
when comparing to male collegiate swimmers. “Swimmer 
Shoulder”, a generic term for overuse shoulder injuries in the 
swimming population occurs with high rate and intensity of 
training. Significant factors that have been found to 
contribute to this pathology are deficits in internal rotation, 
lack of stability, and increased demands on the shoulder. The 
aim for this clinical outcomes project was to evaluate changes 
in range of motion (ROM) total arc of the shoulder, and 
patient-perceived function in female elite swimmers 
throughout a competitive season. Shoulder total arc ROM was 
measured passively with the student-athlete supine. A digital 
inclinometer was used to make it simpler for the clinician to 
assess ROM on their own. The Kerlan-Jobe Orthopedic Clinic 
Shoulder and Elbow Score (KJOC) was used to measure self-
perceived upper extremity function in sport. It consisted of a 
set of demographic and participation questions followed by 
10 visual analogue scale questions about upper extremity 
function during sport. Upper extremity stability was also 
measured using the closed-kinetic chain upper extremity 
stability test (CKCUE). Results showed shoulder ROM (total 
arc) restrictions occurred during times of increased training 
intensity and volume. When patients had smaller total arc 
measurements, the student-athletes reported lower KJOC 
scores for sport related function. There was an increase in 
ROM at a time where intensity, and distance of training were 
decreased. Overall upper extremity stability gradually 
improved over the course of a competitive season. 
 
Key Phrases 
Clinician-rated outcome, college and university patient 
population, patient-reported outcomes  
 
Correspondence 
Dr. McCall Christian, Missouri State University, 901 S. 
National Ave. PROF 160B, Springfield, MO 65897 
816-835-3771. 
E-mail: MChristian@MissouriState.edu  
Twitter: @mchrist10 
 
Full Citation 
Christian ME, Eberman LE. Range of motion changes in 
female elite swimmers throughout a competitive season. Clin 
Pract Athl Train. 2019;2(1):11-18. 
https://doi.org/10.31622/2019/0001.3.  
Submitted: August 31, 2018 Accepted: February 18, 2019 

INTRODUCTION 

Upper extremity injuries, specifically to the 

shoulder, neck, and back, are the most common 
injury in swimming athletes specifically in the 
collegiate setting.1,2 Sallis et al.3 established that 
females sustained shoulder injuries three times 
more often and are five times more likely to 
sustain neck and back injuries than men. When 
these injuries occur, drop off in performance and 
participation can occur due to their debilitating 
nature. Factors such as technique, yardage, 
training, and intensity are contributing factors to 
such injuries. Physical factors like posture, 
technique, strength, and range of motion (ROM) 
may also contribute to higher risk of injury.2 
Intrinsically, factors like integrity of the ligaments 
of the shoulder girdle, core and scapular muscle 
control, muscle imbalances in the shoulder and 
scapulothoracic region and extrinsically, factors 
like high-level, high-intensity training in and out 
of the pool, sports specialties, history of injury, 
and age all contribute to an increased risk of 
injury in swimming.2  

The shoulder joint is complex, allowing for 
substantial mobility, while sacrificing stability. 
Both the dynamic and static stability are reliant 
on the coordination of the rotator cuff muscle and 
complimentary ligaments.4 Any movement, 
especially repetitive movement, requires 
coordination of these static and dynamic 
stabilizers to maintain proper joint position to 
avoid injuries derived from overuse. ROM 
abnormalities have been associated with pain, 
decreases in performance, and the development 
of shoulder pathologies.5 “Swimmer Shoulder” is 
a pathology that occurs with high rate and 

https://doi.org/10.31622/2019/0001.3


Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 2 – Issue 1 – February  

intensity of training,6 and is a generic term for 
shoulder overuse injuries in the swimming 
population.2,3,7  

Swimming athletes have unique mechanics and 
movement patterns and a better understanding 
of dysfunction and pain within this population is 
needed in order to develop prevention 
strategies to avoid overuse injuries. We aimed to 
understand ROM changes and characteristics of 
disease through measures of ROM, upper 
extremity stability, and changing perceptions of 
function over the course of a season. Although 
there are many factors that could contribute, 
deficits in internal rotation, lack of stability, and 
increased demands on the shoulder have all 
been theorized to increase risk of injuries.8 Also, 
previous research in collegiate overhead 
throwing athletes showed changes in rotational 
ROM, over the course of a season.9 However, 
these changes and potential pathology that often 
come from excessive ROM have not been 
explored in swimmers. The purpose of clinical 
outcomes research is to describe patient- and 
clinician-reported outcomes measured in clinical 
practice. The measurements were part of clinical 
practice as a means of assessing various changes 
in student-athletes over the course of a season, to 
help the clinicians working with these student-
athletes identify when they were at an increased 
risk for injury.   

PATIENTS 

Twenty female swimmers (age = 19 ± 1 years, 
height = 85.78 ± 34.26 in., weight = 123.65 ± 
41.40 lbs.) from a Midwestern National 
Collegiate Athletic Association Division I institution 
were followed over the competition season. Each 
student-athlete was cleared to participate in 
sport, per department guidelines that each 
student-athlete is required to be seen by various 
medical personnel as part of a mass pre-
participation screening. All student-athletes 
continued to be active in their sport and training 
regimens throughout the season, including weight 

lifting, conditioning, whole body musculoskeletal 
injury prevention, and core-focused workouts. 
None of the student-athletes were excluded from 
measurement sessions due to injuries suffered 
before or during the competitive season. The 
main objective of the outcomes assessment was to 
observe changes over the duration of the season; 
one student-athlete was excluded from statistical 
analysis for absence from more than two 
measurement sessions. Student-athletes who 
experienced injuries sought treatments and 
inventions on an individual basis with the athletic 
training staff. Because outcomes research is a 
collection of outcomes in clinical practice, 
interventions were not controlled. 

OUTCOMES MEASURES 

Measurement sessions occurred seven times over 
the course of the season by the same clinician. 
Measures were collected monthly with the sessions 
lasting around one hour for the whole team. We 
collected measurements from the start to the end 
of the NCAA collegiate swimming season (lasting 
7 months). The first collection (September) 
occurred before the first official meet and the last 
collection (March) was after post-season 
competition was complete. Each collection was 
completed on a similar day and time each month 
in order to replicate the state of tissue. Many 
factors could not be controlled such as activity 
outside of sport and voluntary additional practice. 
The day and time chosen each week month fell on 
a day that the team had only a single practice 
session. Collection was done before the student-
athletes participated in any team activities. On 
each measurement session day, one clinician 
completed glenohumeral total arc measurements 
and the closed-kinetic chain upper extremity 
stability test (CKCUES) as well as asked the 
student-athlete to complete the Kerlan-Jobe 
Orthopedic Clinic Shoulder and Elbow Score 
(KJOC) on a paper form.  
 
Glenohumeral ROM 
 



Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

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Glenohumeral ROM can be measured in a variety 
of ways. The use of goniometry is the gold 
standard for measuring joint ROM.10 Due to the 
shoulder’s vast mobility and wide ranges of 
motion, finding the correct position to measure 
glenohumeral motion alone can cause some 
difficulties. Collecting passive ROM for the 
shoulder in external and internal rotation can 
sometimes cause difficulties for a single clinician. 
Attempts to avoid inconsistency in student-athlete 
positioning can be tasking for clinicians while 
trying to move the shoulder through the ROM with  

Figure 1.  Digital Goniometer Measure of 
External ROM 

the goniometer. A standard goniometer has two 
working arms that need to be positioned precisely 
with the body and the limb being measured in 
order to gather an accurate measurement. This 
becomes a process that can be challenging to  
recreate consistently. Other options for measuring 
ROM include digital inclinometer,11 bubble 
inclinometer, and video analysis.7 We used a 
digital inclinometer (Saunders Baseline Digital 

Inclinometer, The Saunders Group Inc, Chaska, 
MN) and a nylon fabric strap glued on to 
protective guards to attach the device to the 
forearm (Figure 1). This aided the clinician to 
ensure proper positioning throughout the ROM 
measurement. During measurement sessions, the 
clinician measured bilaterally for glenohumeral 
ROM. We calculated total arc of motion by 
combining measures of external ROM and internal 
ROM while the patient was lying in the supine 
position. The student-athlete was positioned in 90° 
of glenohumeral abduction position as shown in 
Figure 1. The practitioner passively moved the 
patient through the ROM and end-range ROM 
was decided based on the firm end-feel of the 
glenohumeral joint and the rise of the scapula off 
the table.10  
 
Closed-Kinetic Chain Upper Extremity Stability Test 
(CKCUES) 
 
We measured upper extremity stability with the 
CKCUES. The CKCUES test is an easy-to-use 
clinical test that has been validated on a variety 
of populations. It requires very little equipment 
and a brief commitment to complete. The student-
athlete was placed in a pushup position (Figure 2) 
with their hands 36 inches apart (designated with 
tape on the floor), where they were asked to touch 
the supporting or weight-bearing hand with the 
unattached hand and alternate as many times as 
possible within 15 seconds. They completed this 
functional outcome measure three times for 15 
seconds each.12,13 Every touch was recorded as 
one toward the score for that trial. The patients 
completed a 45-second rest between trials. The 
average of the three trials are recorded as the 
final measure.13 Although swimming is an open 
kinetic chain activity, this functional movement 
outcome measure mimics a number of other 
training activities such as dry land activities and 
strength programs. For healthy individuals, there 
is great intersession reliability.14 



Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 2 – Issue 1 – February  

 

Figure 2. Starting Position for CKCUES 
 
Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow 
Score (KJOC) 
 
The KJOC is a patient-rated outcome measure 
created for highly functioning individuals 
participating in sport. In comparison to other 
similar measures, the KJOC has less of a ceiling 
effect allowing for it to measure changes for 
higher functioning individuals.15 Although it was 
originally created for throwing athletes, the 
wording of the questions do not address throwing 
directly, and is therefore applicable to all 
overhead athletes. The first part of the tool 
addresses history of injury and sport participation. 
The second part is a series of 10 visual analogue 
scale questions about current pain or dysfunction. 
The left side of the line represents high levels of 
pain or dysfunction while the right side indicates 
no pain or dysfunction. The tool is scored based 
on an average of the 10 visual analogue scale 
measure from 0 to 10 cm.15 Research studies done 
on the KJOC in other high-level athletes 
demonstrate that this tool is more sensitive to 
athletes compared to other upper extremity 
patient-rated outcome tools.16 This same study 

found that there was a high predictability of lower 
scores if the patient missed practice or game(s) in 
the last year.16 The researchers also found that 
time of administration had no effect on the 
outcome.16 No minimal clinically important 
difference (MCID) has been established for this 
tool. This was also collected at each measurement 
session. 
 
RESULTS 
 
Student-athlete demographic data was analyzed 
using means, standard deviations, frequencies, 
and percentages.  Means and standard 
deviations were calculated for the bilateral total 
arc ROM, CKCUES (average of three trials), and 
KJOC (total score) for each month (Table 1).  We 
analyzed the outcome measures using three 
separate repeated measures ANOVAs and 
significance was set a priori at <0.05.  

We identified a significant main effect for time 
and total arc ROM in the right arm (p<0.001), 
and specifically we identified that months one, 
two, and five deviated more than 5° below 180° 
associating restriction. Months six and seven mean 
measures deviated 7° more than 180° suggesting 
possibly hypermobility. We also identified a 
significant main effect for time and total arc ROM 
in the left arm (p<0.001).  Month one deviated 
10° below 180° and month seven deviated 7° 
above 180° in the left arm. There was a gradual 
increase in CKCUES touches through the duration 
of the outcomes assessment ranging from an 
average of 13.7 touches in the first month to 20 
touches in the last month (p<0.001). The KJOC 
scores indicated high levels of function among the 
student-athletes over the course of the competitive 
season (mean = 88.16 ± 3.29 points [total score 
possible 100 points]). Month two was significantly 
different compared to the other months with a 
mean score of 81.14 points (p<0.001).    

 



Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

15 
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DISCUSSION 

The primary purpose of this outcomes assessment 
was to evaluate changes in passive glenohumeral 
total arc, closed-kinetic chain upper extremity 
stability, and self-perceived function over the 
course of a competitive season in collegiate 
female swimmers. Clinical outcomes research is 
meant to help clinician’s measure patient- and 
clinician-rated outcome measures and to use those 
measures to improve their own clinical practice.  
Sample size and techniques to control data 
collection are not necessary in clinical outcomes 
research and were therefore not utilized here.  
However, based on our data, we were able to 
monitor patients over the course of a season and 
future prevention programs may be developed.   
 
Since the reliability of goniometry measurement is 
varied and often hard to complete with one 
clinician, we chose an alternative method using a 
digital inclinometer. Methods of collection helped 
to free the hands of the clinician in order to assure 
proper passive ROM and to make it more 
clinically applicable. The intra-rater reliability of 
the digital inclinometer is excellent (ICC (3,k) 
=0.94-0.98).18 Other ways to measure ROM of 
the shoulder include bubble inclinometers and 
emerging used of cellphone application. 
Advances in technology and future research on 
electronic goniometer could help in incorporate 
these measures into clinicians’ practice more  
 

 
 
frequently. Changing methods are helping to 
ensure that measurements, especially in the 
shoulder, could be collected efficiently and 
independently.  
 
Largely, we saw more variation on the right arm 
ROM than the left. Month one, two, and five had 
significant restrictions. Restrictions in internal 
rotation ROM has been connected to increased 
rate of internal impingement and posterior 
shoulder limitations.19 Decrease of total arc 
greater than 25° increases the likelihood of a 
patient to experience an upper extremity injury 
by four times.5 Another consideration when 
measuring total arc is humeral torsion. Posterior 
fibers of the rotator cuff and posterior capsule 
have been hypothesized to change orientation 
with significant humeral torsion. This can affect 
ROM measurements19 because the fiber changes 
effect placement of the humeral head on the 
glenoid over time, possibly causing injury. Age 
also plays a factor in identifying these changes 
and addressing postural corrections can help aid 
in prevention.  
 
The CKCUES is an easy and low-cost clinician-
rated outcome measure used to assess upper 
extremity stability in a close-kinetic chain position. 
Although closed-kinetic chain is not a characteristic 
of the swimming motion itself, dry land training 
and other conditioning activities are completed in 
the closed-kinetic chain postures.20 Anecdotally, 
patients complained of more discomfort and 

Table 1. Monthly Outcome Measures 
Month KJOC Total Arc (R) Total Arch (L) CKCUES 
1 88.4±16.1 172.7±14.6 169.7±11.4 13.8±2.5 
2 81.1±19.9 169.1±13.0 177.1±9.4 15.6±2.9* 
3 88.2±12.3 180.4±14.9 178.3±12.5 17.8±1.5* 
4 88.9±13.7 180.2±18.4 178.6±11.8 19.2±3.2 
5 88.8±14.8 175.3±16.5 170.3±15.4 19.4±2.7 
6 90.9±13.2 188.7±12.0 187.0±16.9* 19.5±2.8 
7 90.7±13.5 187.6±21.9 179.4±12.6 20.5±3.5 

Values are expressed in the mean ± standard deviation. 
*Significantly different from previous month (P<.05). 



Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

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strength deficits when completing closed-chain 
activities compared to swimming activities. In the 
previous study, active females, positioned in a 
kneeling stance, produced mean scores ranging 
from 27 to 31 touches. The men in the study, whose 
procedures matched ours, ranged from 24 to 27 
touches on average.14 The mean touch counts for 
the student-athletes in this outcomes assessment 
was well below where other active females and 
males have scored despite positioning.14 A 
connection can be made that due to the physical 
adaptions in open-chain training, participating in 
closed-chain exercise is more difficult and 
therefore could possibly be a cause for injury risk 
or a reduction in performance. Patients showing 
instability or dysfunction while completing this 
stability test should be considered for changes in 
dry-land training and an assessment of these 
deficits before returning to previous activity 
status. It is evident that there could be a learned 
effect when completing the test so frequently. The 
test-retest means found by Tucci et al14, saw 
increases in all populations possibly justifying a 
similar improvement among the student-athletes in 
this study. In total, the CKCUES may not be a great 
indicator of injury in open-chain activities but 
should be used to help guide closed-chain 
training. 
 
The KJOC was a tool developed for specific high 
functioning individuals participating in sport. It has 
sensitivity and reliability and is thought to 
demonstrate more subtle changes in high 
functioning individuals. The student-athletes we 
monitored scored 88 points for all seven months 
with a significant decrease in month two. 
Measurements returned to the 88-point range 
after month two. Kraeutler et al.21 reported 
normalized values in asymptomatic professional 
baseball players well above 90 points. Out of 44 
players, only seven reported scores below 90.17 
Our population was significantly below the 94.8 
points reported previously.21 The differences 
could be attributed to the higher impact that 
swimming can have on upper extremity function, 
specifically where baseball involves the use of 

unilateral shoulder movement, the nature of 
swimming is bilateral. The sport level may also 
play a role in the KJOC scores. 
 
CLINICAL APPLICATION 
 
Overall, we observed significant increases in total 
arc ROM bilaterally, improved upper extremity 
stability, and consistent perceived function in 
collegiate female swimmers. Future 
implementations of these measurements sessions 
should look to correlate mileage and training 
intensity to determine the relationships between 
these changes and workload.  It is very likely that 
the student-athletes developed a learned effect 
to the upper extremity stability testing and those 
findings may not inform clinical practice; however, 
student-athletes did report pain doing this test, 
indicating that further exploration of swimmers 
and this test may be necessary. Identifying risks of 
injury and making decisions on prevention 
strategies should incorporate many different 
factors such as ROM, stability, and self-perceived 
function. Similar clinician-rated outcomes research 
has examined rotational ROM outcomes in the 
baseball and softball patients9 and patient-rated 
outcomes research with the KJOC scores in elite 
level baseball players.9 We found similar 
changes in rotation ROM described, but found the 
student-athletes in this population scored 
substantially lower than elite overhead throwing 
athletes. Although both populations are 
considered overhead athletes, swimming includes 
bilateral use of the upper extremity while 
throwing utilizes unilateral workloads and the 
difference in mechanics may require specific 
considerations when developing prevention 
strategies.  
 
Prevention strategies for the shoulder and upper 
extremity in the literature are inconsistent. Practice 
patterns for prevention among team-based care 
secondary or tertiary in nature. By conducting 
similar clinical outcome measures can provide 
information specific to the population and help to 



Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 2 – Issue 1 – February  

guide changes in injury prevention on a primary 
level. Although these are preliminary measures to 
understand changes over the course of a 
competitive swimming season, it has described the 
benefits and limitations of various patient and 
clinician-rated outcome measures. Once more 
appropriate measures are identified for this 
population, future clinical outcomes research could 
be used to test prevention strategies.   
 
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All rights reserved. ISSN Online 2577-8188                                                                              Volume 2 – Issue 1 – February  

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