Management and rehabilitation of long term surfing injuries.

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

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.

GOT A SURFING INJURY THAT JUST WILL NOT GO AWAY!?

HARBOURSIDE PHYSIOTHERAPY -
WESLEY PLACE
NEWLYN
PENZANCE
CORNWALL
TR18 5AZ

Tel: (01736) 366224

Email: harboursidept@btconnect.com OR info@harboursidephysiotherapy.co.uk

Listed below are just a few examples of the exercises used at the harboursidephysiotherapy clinic.

Strengthening EXT/IR

• Repetition: 10
• Sets: 2
• Frequency: twice daily

Tie elastic in front of you at head level.

Hold tightly the elastic with the palm facing upwards. Your arm is straight at shoulder level.

Pull arm straight down and internally rotate the arm so that when you reach end position the palm face backwards away from body.

Maintain arm straight, shoulder back and torso stable during the exercise.

Slowly return to initial position

Strengthening Ext/retraction

• Repetition: 10
• Sets: 2
• Frequency: twice daily

Tie elastic in front of you at waist level.

Hold tightly both ends of elastic in both hands. Your elbows are slightly flexed.

Keeping the elbows locked, shoulders down and torso stable, pull elastic backwards as far as possible by joining shoulder blades together and arms back

Slowly return to initial position and repeat.

Strengthening Ext/retraction

• Repetition: 10
• Sets: 2
• Frequency: twice daily

Stand in a split stance.

Tie elastic in front of you at waist level.

Hold tightly elastic with one hand. The back leg is on the same side as the arm pulling. Your elbow is flexed 90 degrees.

Pull elastic backwards as far as possible by joining shoulder blades together and rotating upper body. The head and hips must remain facing straight.

Return slowly to initial position and repeat.

Strengthening Ext/retraction

• Repetition: 10
• Sets: 2
• Frequency: twice daily

Tie elastic in front of you at waist level.

Hold tightly elastic in one hand.

Lift one leg up (elastic side) and pull elastic backwards as far as possible by joining shoulder blades together and arms back, shoulders down and torso stable,

Keep your balance on one leg at all times.

Slowly return to initial position and repeat.

Strengthening Horiz ABD/ER

• Repetition: 10
• Sets: 2
• Frequency: twice daily

Tie elastic in front of you at waist level.

Hold tightly both ends of elastic in both hands. Your elbows are slightly flexed.

Pull elastic backwards as far as possible by joining shoulder blades together, bending elbows 90 degrees and keeping arms horizontal.

Keep shoulders back and torso stable during the exercise.

Slowly return to initial position and repeat.

Strengthening PNF

• Repetition: 10
• Sets: 2
• Frequency: twice daily

Stand in a lateral split stand.

Tie elastic high down on one side to a door.

Hold tightly elastic with both hands at knee level with shoulders back with your weight on the leg closest to the door.

Transfer weight to the other leg, rotate trunk using abdominals and upper back and pull elastic towards ceiling.

Slowly return to initial position with control and repeat.