ALL YOU NEED TO KNOW ABOUT SURFING INJURIES
The literature identifies multiple mechanisms which contribute to the following injuries. This information has been collated from current literature as well as speaking with experienced Physiotherapists who have spent years assessing and treating these conditions in surfers. A sound understanding of these mechanisms can be used proactively in conjunction with subjective and objective assessments to devise sport specific and patient specific strengthening and exercises to ultimately reduce the likelihood of injury and keep surfers surfing.
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The most commonly injured joints for acute injuries in surfing are the shoulder, knee and ankle (Hohn, Robinson, Merriman, Parrish & Kramer, 2018). The injuries listed below are the most prevalent injuries occurring at these joints. The mechanism of injury will be outlined for each below.
MCL INJURIES:
The Medial Collateral Ligament (MCL) is the most commonly injured aspect of the knee in surfers, in one study accounting for 49% of all sustained knee injuries (Hohn, Robinson, Merriman, Parrish & Kramer, 2018). The back leg is most commonly injured due to the valgus stress placed on the knee for landing manouvres such as turns or aerials. Here, the surfer adopts a 'knee-in' position as the surfer must place their body weight predominantly over the leading leg to absorb landing forces and regain balance (Inada et al., 2018). This is shown in the image to the left.
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Common reasons for the MCL being injured is due to excessive forces absorbed by the knee, commonly with excessive knee valgus, when landing from a turn on usually bigger waves or from aerials.
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Other reasons this may occur is if the surfer lands in the 'flats' of the wave following an aerial or turn. The flats of the wave is seen as the area in front of the steep curve of the wave face. Landing here will increase landing forces at the knee.
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The surfer may also be 'double-bounced' after landing an aerial or turn, where upon landing water from underneath the board presses the board upward increasing the valgus force at the knee, often unexpectedly and prior to the surfer completely bracing for impact.
ACL INJURIES:
ACL injuries occur less frequently than than MCL tears, however sustaining an ACL injury in surfing has been shown to require increased rates of hospitalisation (Woodacre, Waydia & Wienand-Barnett, 2015) and oftentimes requires a longer time out of the water to rehabilitate the knee and thus is considered to be more serious.
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There are few studies looking into the mechanism of ACL injuries in surfers, however it is understood that the majority of these injuries are classified as 'non-contact' as there is unlikely to be an external perturbation directly targeted towards the knee. Given our understanding of these injuries in other sports, the ACL is often damaged when landing or from sudden deceleration or change of direction (Dai, Herman, Liu, Garrett & Yu, 2012). It is therefore likely that ACL injuries in surfing occur when landing from an aerial manoeuvre or turn on a large wave, or potentially whilst committing to a powerful turn, where the back leg produces excessive force and torque, similar to quickly changing direction in land based sports (Hohn, Robinson, Merriman, Parrish & Kramer, 2018), placing the ACL under strain.
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Two of the most well-known cases of ACL injury occurred in 2019 where 2x World Champion John John Florence ruptured his ACL in competition and 3x World Champion tore his ACL whilst free-surfing.
John-John's occurred on a very large wave where he approached the lip (breaking section of the wave) with a great amount of speed to attempt an aerial. The external force from the lip hit the underside of his board and compressed his back knee, rupturing his ACL. John John was away from competition for 5 months.
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Mick Fanning's ACL injury occurred whilst performing a big forehand turn, where a lot of forced was pressed through the tail by Mick's back leg whilst changing the direction of the board (somewhat similar to a cutting manoeuvre in soccer).
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The video above aims to show the high demand placed on the knee joint and the unexpected forces that can subject the knee to injury. Specifically, the landing component where the knees must absorb force from both landing and the potential white water pushing the board upward, as well as the loss of balance and recovery to stand up again which places the back knee under extreme valgus stress. I was not injured in this video at all thankfully.
LATERAL ANKLE SPRAINS:
Ankle injuries as a whole account for 22% of all acute surfing injuries, 72% of which are lateral ankle sprains (Inada et al., 2018).
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These sprains often occur upon improper landing from an aerial manouvre (Inada et al., 2018) and usually impact the surfer's back leg (Hohn, Robinson, Merriman, Parrish & Kramer, 2018). Here, the ankle is subject to excessive force, particularly if landing in the 'flats' of the wave as previously discussed (Furness, Hing, Walsh, Sheppard & Climstein, 2015), where the ankle may excessively invert.
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It has been shown that the recent increase in aerial manoeuvres in surfers across the globe has increased the incidence rate of this injury (Furness, Hing, Walsh, Sheppard & Climstein, 2015).
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The above video is an example of an attempted aerial manoeuvre. Landing on the white wash as in this video often makes for a softer landing and places the ankles under less stress. If the surfer is to land in the flats (the flat water area in front of the wave) the ankle is subject to far more stress and sprains are more likely to occur.
ROTATOR CUFF TEARS:
The shoulder has been shown to have the highest incidence of acute injuries in surfers (Furness et al., 2015) and rotator cuff tears account for approximately 40% of shoulder injuries in surfers (Hohn, Robinson, Merriman, Parrish & Kramer, 2018).
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Shoulder injuries in general including rotator cuff tears require surgical intervention more so than any other injury sustained by a surfer (Hohn, Robinson, Merriman, Parrish & Kramer, 2018). Possible mechanisms of injury postulated by research has included paddling, which the surfer spends on average 45% of their session doing and may lead to acute inflammation or impingement if the surfer uses improper biomechanics. Strength discrepancies between the internal and external rotators or simply external rotator weakness/internal rotator fatigue may also contribute (Furness et al., 2015).
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Another possible mechanism of injury is the pop-up, where a surfer will press themselves up from a lying to standing position on the board at the beginning of the wave. This is commonly an explosive movement that can place stress on the anterior structure of the shoulder such as the subscapularis and anterior supraspinatis tendons (Dimmick et al., 2018). The duck-dive, where a surfer will push the board under a wave whilst paddling in the lineup may also place stress on the anterior structures in a similar way.
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Lastly, falling off the board and landing awkwardly in the water may be another acute trauma incident injuring the rotator cuff muscles or tendons (Dimmick et al., 2018). Factors such as wave height and how powerful the wave is may predispose the surfer to a rotator cuff injury as more force will be placed through the shoulder joint upon impact when falling.
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The video above shows the paddling action and that small waves can be difficult to catch! Take note of the extension required through the spine to allow the chest to lift up and enable proper shoulder movement. Also think of the load placed on the internal rotators (working very hard through paddling) versus the external rotators (working very little). The later aspect of the video shows the pop-up, where the chest is pressed up and the shoulders must maintain a strong and secure position to allow the feet to pop through.