surfing injuries | surfing training

To its hard-core adherents, surfing is not just a sport but a way of life, and as with any activity that dominates your life, injury can be devastating. Despite the obvious dangers, surfing, in common with other extreme sports, is going through a dramatic increase in popularity, which means sports therapists will soon be treating injured surfers – if indeed they have not already done so. The sport is fascinating, and offers some real challenges for injury rehab and prevention.

Surfing is physically demanding, repetitious (the paddling element) and often hazardous, particularly for beginners and those who like to push the boundaries. Advances in surfboard technology enable more speed and sharper turns. Greater popularity means more crowds. Higher standards, more public exposure and increased competitiveness will push those at the top end to attempt more radical manoeuvres and tackle bigger waves. There are going to be more casualties, and many of them will be among beginners with low skill levels, poor knowledge of conditions and inadequate fitness.

Injury overview

Lacerations to the head, lower leg and foot appear to be the most common injuries, usually caused by contact with the surfer’s own or another surfer’s board or fins (the rudder on the underside of the board); with the ocean floor, or with beach litter.

Soft-tissue injuries comprise the second-largest category, ranging from contusions to acute strains or sprains to the lumbar and cervical spine, shoulder, knee and ankle.

Fractures occur frequently. The head is the most common site, mostly involving the nose and teeth, and many ribs get broken.

Eyes and ears are vulnerable. Eye injuries can result from direct trauma but also chronically from excessive UV light reflecting from the water surface, the drying effect of the wind and exposure to salt water. The surfer’s ears can suffer in two specific ways: firstly, a ‘wipeout’ (coming off the board while riding a wave) can perforate an eardrum; and secondly, a chronic condition may develop involving bony growths within the external ear canal as a result of ‘cold water, spray and wind rushing in and out of the canal, stimulating the tissues to produce excessive bone growth’⁽¹⁾. This causes a loss in diameter of the ear canal and a consequential decrease in hearing. It is known as surfer’s ear.

Craniospinal injuries are rare but of particular concern because of the long-term consequences. (One study⁽²⁾ found craniospinal injuries to be the most common form, but this finding is less odd when you know that the study was done on Hawaii’s North Shore, ‘where spectacular hard-breaking surf breaks within a few yards from shore in shallow water’.)

Acute musculoskeletal injuries will usually result from a wipeout. Contact with the ground surface – whether it be reef, rock or sand – can cause injury, the type and extent depending on the surfer’s position and contact area. Common injuries include

over-flexion of the cervical or lumbar spine
forced shoulder depression and contralateral lateral flexion of the cervical spine resulting in traction to the brachial plexus
landing on the point of the shoulder causing trauma to the acromio-clavicular joint or in adolescents fracture to the clavicle or the shoulder being forced into anterior subluxation.

Acute knee and ankle, ligament and joint surface injuries can result from a big drop at take-off. When standing up on fast, steep waves, the surfer’s feet can leave the board and then find it again at the bottom of the wave. If the surfer becomes unbalanced for whatever reason, he/she can land off-centre, putting excessive rotational or medial/lateral force through knees or ankles.

Overuse injuries of the shoulder, neck, back and elbow are common and relate to prolonged time spent paddling, tummy down, on a board. For more information on injury statistics, see ‘Surfing Injuries in Otago and Southland, New Zealand’, a research project by Rede Frisby⁽³⁾.

Prevention

Protective equipment can help to prevent injuries. Hard plastic or rubber nose guards fitted to the front tip of the board can soften the blow if contact is made during a wipeout. A wetsuit, worn for warmth, can help guard against lacerations from fins. A hood attached to the suit will also protect a surfer’s eardrums in harsh conditions. Surfers often wear helmets in large waves or when surfing over reefs. Booties are worn for warmth and will protect against lacerations from an underlying reef – although many surfers forgo them because they impair their ‘feel’ for the board. In large surf, selecting a longer leash can also be very helpful in preventing contact injuries with the board.

Good knowledge of the specific surfing conditions and the right equipment are wise precautions against injury. But inexperienced surfers in particular often enter the water ill-prepared.

Management and rehabilitation

Acute injuries should be managed as they would for any other athlete, but particular emphasis should be placed on knee and ankle stability and proprioception during a surfer’s rehabilitation, for obvious reasons. Late stage rehabilitation should include single-leg squatting; a functional progression would be to add variations of trunk control while maintaining knee alignment, using for instance trampette, wobble board or other external perturbation. The therapist should aim to return the surfer to a much a higher level of fitness than the average population and should always place emphasis on returning a full range of flexion after knee injury and dorsiflexion after ankle injury.

Chronic injuries are far more likely to occur in beginners and older people. Beginners are less likely to be conditioned to paddling, yet will often spend longer periods doing it, because of their inefficiency and inability to read the surf. Beginners can spend extended periods struggling through the break zone.

Beginners and older surfers are also less likely to demonstrate good flexibility in important areas. The most common overuse injury is to the shoulder, similar to those suffered by swimmers. Rotator-cuff impingement and tendinitis give pain in the anterior shoulder and refer pain to the deltoid region. The therapist should concentrate on the range of scapular protraction and lateral rotation and scapular stability. Often there will be a significant imbalance between internal and external rotator-cuff strength, which needs to be addressed.

In terms of range of movement, particular attention should be paid to infraspinatus, teres minor, rhomboids, levator scapula and thoracic spine extension. Just like swimmers, surfers are prone to develop instabilities within the shoulder, and this often occurs in conjunction with the above problems. Excessive stroke length, which overloads the relatively hypovascular zone of the supraspinatus tendon, can also be a predisposing factor to injury.

Surfers need to be able to hold the upper chest off the board for prolonged periods. If they are unable to do this because of a poor range of movement or because they lack endurance in their back extensor muscles, this will predispose them to shoulder overuse injuries. Keep in mind that shoulder pain doesn’t always mean local shoulder pathology.

When paddling, the cervical spine is forced to spend prolonged periods in extension. The surfer will be forced further into cervical extension if they have poor thoracic extension or weak muscular endurance. All inexperienced surfers will at some stage feel discomfort through the back of the neck or between the shoulder blades if they spend any decent amount of time in the water, which you need to do to learn. It is a matter of getting accustomed to the position.

Most of the initial discomfort will be muscle fatigue. If the symptoms get beyond mild discomfort and start to affect the time that the surfer can spend in the water, then it becomes a problem. Look to the following areas as possible causes:

irritated cervical facet joints from prolonged compression;
chronic trigger points through upper trapezius, levator scapulae, rhomboids, erector spinae and upper cervical extensor muscles;
neural tension dysfunctions;
thoracic outlet syndrome.

These areas should also be included as differential diagnoses for shoulder pain.

Key points for rehabilitation from these injuries include building strength and control of lower trapezius and serratus anterior, to avoid an elevated scapula position; range of movement in areas mentioned for the shoulder; and endurance of lumbar and thoracic spine extensors. Pain from the thoracic spine will often manifest between the shoulder blades or into the chest wall. This could include chronic trigger points and irritated facet or costovertebral joints.

These injuries through the upper quadrant will all result from a similar postural pattern and the surfer will often be experiencing symptoms from more than one area.

During a session a surfer will spend prolonged periods with their lumbar spine in extension and then rapidly force it into flexion, moving from lying to standing when catching a wave. All structures throughout the lumbar spine are at potential risk of injury: forced disc compression, facet joint compression when paddling, muscle fatigue leading to chronic trigger points, and excessive shear forces when lying on the board. While chronic lumbar spine injuries are not common, pre-existing injury will play a big role in the level of risk to any of the structures of the lower back. However, the therapist should focus on:

lumbar spine flexion range of movement, particularly through the thoracolumbar junction;
hip flexion range to unload the lumbar spine when going from lying to standing;
lumbar spine extensor endurance;
adequate local lumbar spine stability in an extended position.

Flexibility is key

A surfer’s flexibility is very important to both injury prevention and performance. Surfers are notoriously bad at warming up. You don’t often see surfers stretching on the beach. It is probably a combination of not knowing how to work on flexibility and rushing to get among the waves. But 10 minutes of loosening up before jumping in the water can make a big difference to performance and injury prevention. In particular:

thoracic spine extension
posterior rotator cuff
scapular retractors
pecs
latissimus-gluteus myofascial system
lumbar spine flexion/extension
hip flexion
hip rotation
ankle dorsiflexion

Hip rotation range of movement is required for manoeuvring the board, but also because a lack of range can often affect hip flexion range of movement. Hip internal rotation stretches in hip flexion and extension and a figure 4 stretch for external rotation will often help increase hip flexion range of movement.

Conditioning training

Despite its obvious and growing popularity, surfing has not received much attention from sports science. Probably because it is such a pure and expressive sport, it has been difficult to devise land-based training programmes. Now that the professional stakes are higher, training techniques for surfing are evolving. Surfing is a dynamic and explosive sport. It involves major challenges to balance, so core stability work should clearly form an integral part of training. And as with any training of this type, it should be kept functional. Alongside this, strength matters: promote closed-chain leg strength exercises such as squatting, and upper-body strength work to push off the board. Work towards developing power. Plyometrics and agility exercises are ideal and should be included in a phased programme. But crucially, do not allow any strength programme to compromise flexibility.

To challenge the athlete further, combine strength and stability by using unstable surfaces (squatting on a swiss ball or single leg squats with opposite single arm cable pulls). And while you stretch your professional creativity in pursuit of the perfect land-based conditioning programme, bear in mind what all surfers already instinctively know: if the surf is pumping, there is no better training than surfing.

References

Booth, G (1988): Health Risks and Injury Prevention.
Allen, R et al (1977): Surfing Injuries at Waikiki.
Frisby, Rede: Surfing Injuries in Otago and Southland, New Zealand can be viewed as a pdf document from www.ussurf.org/documents/surfinjurythesis.pdf.