RECOMMENDATIONS
SUBJECTIVE ASSESSMENT:
The primary objective of this screening tool is to gain an understanding of where a surfer may be predisposed to injury. Based off these findings it’s important that as Physiotherapists we can implement a program that targets our findings from the subjective and objective screening to reduce the surfer’s risk of injury.
It is important to note that general strength and conditioning of joints susceptible to injury is important for surfers. In terms of how this translates to practice, it may be useful to have a conversation with the surfer about the benefits of increasing strength to reduce risk of injury, which may then lead to a more generalised strengthening program of these joints where abnormalities or impairments were not found upon screening. Furthermore, it is recommended that general strength and conditioning programs for joints prone to injuries should be undertaken even if there are no abnormalities found upon physical screening but the questionnaire has found them to be at a high risk of becoming injured due to high frequency of surfing, surfing in competitions, performing aerials, and having prior injury (Furness et al., 2015).
Age/time in sport:
The longer one has surfed, the more susceptible they are to injury due to the muscle imbalances that may have been created over time. It has also been shown that older surfers over 38 years of age are more likely to sustain chronic injuries (Furness, Hing, Walsh, Sheppard & Climstein, 2013). Therefore, a strong recommendation for a strength and conditioning program should be made to all surfers who don't currently complete any strength training and are over 38 years of age.
Surfing stance:
The loads placed on the back leg in surfing are substantially greater in turning manoeuvres and often when landing aerials. Understanding which is the surfers back leg when surfing will be important to consider when assessing strength and other lower limb surfing specific physical assessments. If the back leg appears to have weakness or reduced range of motion it is very important this is targeted in their exercise program.
In surfing, a 'natural' stance is where the surfer rides the wave with their left foot forwards. A 'goofy' stance is where the surfer rides the wave with their right foot forwards.
Competitive status:
It extremely important that elite surfers partake in a strength and conditioning program as the loads they place their joints under, both in terms of the manoeuvres (e.g. big aerials) they perform and the frequency and intensity they surf is far greater than their recreational counterparts, this shown by competitive surfers injury rates being 1/3 greater than recreational surfers.
It is recommended that even if the surfers risk of injury screening through their physical assessments does not predict an increased risk, that competitive surfers have a strength and conditioning program designed to build their strength, endurance to increase their joint tolerance to load and to minimise the potential strength discrepancies which is often associated with increased surfing frequency over a long period of time.
Aerial manoeuvres:
Surfers performing aerial manoeuvres are at the highest level of risk of all surfers. If the physical assessments shows any signs of increased risk of injury at the knee or ankle joint as well as landing mechanics and dynamic knee and ankle stability, then this is of utmost importance to address in their exercise program for all surfers completing aerials.
The research also suggests that it would be beneficial for all surfers who complete aerials to have a program including strength, proprioception and flexibility to reduce the likelihood of lower limb injury as these manoeuvres place great stress on the knee and ankle joints (Furness, Hing, Walsh, Sheppard & Climstein, 2013).
Landing aerials in surfing rarely allows for an equal distribution of load across both legs. It is therefore important to target bilateral and unilateral landing drills. Moreover, aerialists have been shown to have a significantly higher loading rate of their rear limb when landing aerial manoeuvres, placing increased stress through their rear leg, therefore rear leg strength and range of motion is extremely important to screen for (Forsyth, Riddiford‐Harland, Whitting, Sheppard & Steele, 2020).
Furthermore, Freeman et al (2013) identified that the ability to land aerial manoeuvres requires hip and knee stability under eccentric loading, this suggesting that eccentric exercises may be of use in conjunction with landing based exercises to reduce a surfers risk of lower limb injury when performing aerials.
PHYSICAL ASSESSMENTS:
General range of motion and strength screening:
This aspect of the physical assessment is important to provide context to any impairments found in the surfing specific physical assessments and also to inform the Physiotherapists of any unknown or pre-existing issues (e.g. from prior injuries) which may impact increase the surfers risk of injury. Any abnormalities found should be considered against the questionnaire and the other physical assessments and addressed in the exercise program prescribed by the Physiotherapist.
Low ER/IR ratio:
Strengthening of the external rotators is important as surfing over a long period of time can accentuate the differences between the external rotator and internal rotator strength of the shoulders. A great discrepancy between the two is linked to increased risk of injury, thus strengthening the external rotators through resistance exercises with the aim of getting this ratio closer to 1 will aid in reducing the risk of shoulder/rotator cuff injury in surfers (Furness, Schram, Cottman-Fields, Solia & Secomb, 2018). Paddling over time may also act to shorten the internal rotators, thus increasing the external rotator strength as well as stretching the internal rotators may be helpful (Langenberg et al., 2021).
Low posterior shoulder endurance:
It is important to compare sides from this test to understand strength/endurance discrepancies which may contribute to poor biomechanics/paddling technique once fatigued when paddling.
For male or female surfers reaching their point of fatigue by 46 and 47 seconds respectively, the posterior shoulder endurance test can also act as an exercise intervention to build endurance in surfers. Endurance is targeted with low weight and high number of repetitions, thus progressively overload can be applied by increasing the number of repetitions over time. The weight can then be increased over time at the Physiotherapists discretion.
Low spinal extensor endurance (as measured by the Biering Sorenson test):
With low extensor muscle endurance (e.g. test score below 176 seconds), compensations when paddling are likely, negatively impacting the position of the shoulder throughout paddling and predisposing the shoulder joint to injury.
Reduced thoracic extension as a result of poor endurance whilst paddling in surfing has been thought to increase the surfers risk of scapula dyskinesis which may subsequently lead to impingement around the shoulder (Langenberg et al., 2021), thus exercises to target endurance of the spinal extensors including lumbar and thoracic extension exercises should be included.
Low dorsiflexion range of motion (as measured by the Knee to Wall test):
It has been shown that having a large degree of dorsiflexion > 13cm greatly reduces risk of ankle injury (Gabbe, Finch, Wajswelner & Bennell, 2004). Therefore aiming to increase dorsiflexion range through calf stretching or movement with mobilisation into dorsiflexion may be useful, aiming to achieve a knee to wall test result of 13cm.
Low Y balance test individual reach and composite scores:
Patients who achieve low scores for the Y-balance test, these being differences in between-limb anterior reach scores of greater than 4cm and a composite score of less than 89% are at an increased risk of lower limb injury and are indicative of reduced neuromuscular control and stability (Freeman, Bird & Sheppard, 2013). These results should be considered in conjunction with lower limb range of motion and strength results and single leg squat measures to identify the factors contributing to reduced scores.
Contributing factors should be targeted in an exercise program, whereby reduced knee or ankle range should be targeted via stretching, and poor postural control at the hip, knee and ankle can be targeted through strength training at the target muscle groups.
Proprioceptive training is likely to be effective also where double or single leg stance, progressed with eyes closed or unsteady surfaces may be an option for Physiotherapists.
Single leg squat test impairments:
If a Trendelenburg sign is present, hip strengthening is required. Hip abduction muscles such as gluteus medius and gluteus minumus should be targeted through strengthening exercises. Exercises can be selected and progressed by the Physiotherapist. Recommended exercises in the early phases are the isometric single leg wall press, side lying clams, side lying hip abduction, standing hip abduction with resistance band. These can then be progressed with more complex strengthening exercises and increased resistance once correct activation has been achieved. Some examples include single leg bridge, single leg dead-lift, step-ups to high knee, Bulgarian squats.
Low hamstrings to quadriceps ratio:
The hamstrings are likely to be weaker which as discussed can be a factor in predicting ACL injury in landing and may also reduce knee flexion in landing and turning manoeuvres in surfing which may also compromise the ankle. Research has shown that patients who do not regularly train their hamstring muscles and have powerful quadriceps decreases the antagonistic relationship of the hamstring in landing tasks which therefore increases the risk of injury (Rosene, Fogarty & Mahaffey, 2001). Therefore, knee flexion strengthening exercises should be completed regularly and should aim to bring this ratio closer to 1. It is also important to translate this strength into function, complimenting increases in hamstring strength with integration of proper landing mechanics into the surfers training.
The drop jump test impairments:
There may be factors contributing to decreased hip, knee or ankle range of motion, dynamic knee valgus or ipsilateral trunk rotation and thus this test must be considered in conjunction with prior range of movement and strength screening as well as the single leg squat test as this test alone is not a good predictor of lower limb injury.
Landing mechanics should be targeted in conjunction with any range of motion or strength deficits found. Landing mechanics should firstly focus on landing on a stable surface with even weight distribution between legs, knee flexion past 30 degrees and maintain proper hip, knee and ankle stability throughout. Progressions can include landing on uneven surfaces and then preference weight onto the surfers leading leg which will replicate the landing position for many aerials and turns that surfers perform.