Chronic Injuries: Avoidance and Rehabilitation 

All athletes look for effective methods of dealing with injury. Some of the most frustrating injuries come from overuse. Surfers and other athletes may try to “work through” their injuries and not seek medical attention because of fear that doctors will callously say they need time away from surfing. People that do seek medical attention may receive less than optimal care because of a specialist’s unfamiliarity with surfing injuries or the surfers’ unfamiliarity with medical specialties. This unfamiliarity may lead any athlete to pursue unlicensed medical care. Eastern therapies are quite effective the majority of the time with Yoga, Qi Gong and Tibetan Rites followed by the world's best athletes. A surfer who has been educated about surfing medicine may be more able to identify appropriate and inappropriate treatments in both Eastern and Western medicine.

Sprains and Strains

Warm-ups and cool downs (click on Integrated Qi Gong Fire and Water links above) prevent sprains and strains when properly done. From a medical perspective, it is important to define sprains and strains as well as factors that influence their healing. Many athletes will begin taking ibuprofen or other medicines to deal with sprain and strain type pain. This may end up being counterproductive as some medicines such as ibuprofen (Motrin, Advil) and celecoxib (Celebrex) may increase scar tissue formation. Other medicines, such as piroxicam and meloxicam may be beneficial in early treatment of injuries and corticosteroids have shown modest benefit in aiding muscle healing but require a doctor’s prescription. To bypass the prescription process, or by a preference for “natural” therapies, research has gone into noni, aloe, boswellin and curcumin, bromelian and papain compounds derived from aloe, rice, pineapple and papaya respectively among other remedies. Whereas intense medical research and clinical trials of prescription medicines drives the use of medicines such as piroxicam and meloxicam, positive testimonials and basic science research often drives the use of supplements. A responsible use of both may help the very surfers who are well known for multidisciplinary approaches.  

Noni from Maui

Strains in Surfing

The shoulder, neck, back and hip tend to be predominantly vulnerable to strains in surfing. Strains are partial to complete muscle tears and are graded on a scale of 1-3. Grade 1 strains are associated with microscopic tears within the muscle fibers. There is no loss of strength and the muscle itself should heal within 10-21 days with minimal intervention. Grade 2 strains have reduced strength as the muscle fibers have been partially torn. These injuries require physical therapy and may take up to four weeks to heal. Grade 3 strains are a complete muscle rupture and often require expert care and radiographic evaluation. Swelling is common with Grade 2-3 strains.

Overuse type strains are generally Grade 1 and have an often distinct pain pattern. During surfing the pain is absent until one to two hours after surfing or training. Some rest from surfing will be necessary as chronic exacerbation can lead to scar tissue deposition and further rupture. Acute muscle and tendon injuries are associated with a continuous type pain.

Isometric exercises are important for the rehabilitation of muscle strains and should be done first followed by isokinetic exercises. Isometric exercises involve contracting the muscle without changing its length whereas isokinetic exercise occurs through the full range of motion. See individual exercise prescriptions for examples of isometric and isokinetic exercises for specific injuries. Isometric exercise enhances neuromuscular strength while isokinetic exercise builds the muscle itself along with its strength. Gentle controlled stretching should accompany rehabilitation to prevent shortening by scar tissue. Avoid active stretching in the first five days of any injury to prevent muscle spasms unless certain of heat-associated cramps as the cause.

 

Sprains in Surfing

A sprain is an injury to a ligament and can occur anywhere ligaments exist in the body (which is everywhere). Ligaments are tough fibrous tissues that hold bones together across a joint. Sprains can cause pain or instability at these points. Trained sports medicine physicians may stress these injuries to test the integrity of the ligament. However, only trained specialists should do this because of risks involved with displacing an underlying fracture in the area, such as a thumb sprain with a proximal phalanx fracture. Sprains are graded on a scale of 1-3, with 3 being the most severe.

Grade 1 sprains do not cause instability. They are associated with microscopic tears within the ligament. While there is pain and swelling, these injuries usually heal with time, rest, ice, compression wraps and elevation of the injury. Grade 2 sprains are partial ligament ruptures and may cause laxity and some instability within the joint, may require aggressive physical therapy and sometimes bracing along with prolonged rest, icing, compression and elevation. Grade 3 sprains are complete ruptures of the ligament and may be less painful than Grade 2 sprains with greater swelling. Magnetic resonance imaging (MRI) may be used to assess need for surgical stabilization or determination to brace the joint while the ligament heals. Most overuse sprains are Grade 1 but may progress to Grade 2 by surfers overly defiant to pain. Common overuse sprains include surfer’s elbow and multidirectional shoulder instability.

There are 3 phases of overuse injury healing: an inflammatory phase, a “fibroproliferative” phase where scar tissue forms, and a maturation phase where scar tissue shrinks while “functional capacity” recovers. Once functional capacity recovers, an injured surfer may return to surfing.

Several modalities can be used to accelerate return to functional status, including icing the area for twenty minutes up to four times daily, corticosteroid injections by a sports doctor and either electrical stimulation with corticosteroid cream (iontophoresis) or electrical stimulation alone (TENS). Icing is the only nonprescription modality listed and has been used since ancient times as an anti-inflammatory. TENS units can be purchased or prescribed by a sports doctor and applied by skilled personnel such as an athletic trainer.

Heat, contrary to popular opinion, will increase inflammation and swelling within the first three days of an injury and should be avoided unless certain of a muscle spasm (knot) without sprain or strain. Hot-tubs, hot-packs, ultrasound, bone-stimulators and “cold-laser” therapy are all forms of heat therapy. Musculoskeletal ultrasound has been emerging as an important diagnostic tool for sprains and strains and also has value as both a therapeutic heat modality and guidance system for injections. Heat is primarily beneficial for chronic muscle spasm after strain has been ruled out at least 72 hours after initial injury.

“Prolotherapy” or “platelet-rich-plasma injections (PRP)” have been receiving increased media attention as many elite and professional athletes have been receiving them. These injections involve drawing blood, treating it, and then re-injecting it. Prolotherapy involves treating the blood with dextrose while PRP involves drawing blood, centrifuging it and reinjecting the platelet-rich plasma. These processes actually increase inflammation, like heat, but now with the aim of stimulating growth factors shown to heal chronic muscle and tendon injuries. They are not acute injury remdies. The injections are banned by the World Anti-Doping Association (WADA) and, in turn, the International Olympic Committee (IOC) and the International Surfing Association (ISA) but not the pro-circuits (ASP), yet. Many traditional complementary and alternative therapies popular among surfers including acupressure, acupuncture, cupping (pinpricks and suction to acupressure points) and moxibustion (incinerating herbal compounds at acupressure sites) have theoretical and anecdotal similarity to prolotherapy and PRP.

Hyperbaric oxygen therapy has been around for almost a century. The chamber is sealed from the outside atmosphere and pressure is increased on the inside of the chamber. The occupant inside the chamber puts on a breathing device that supplies him with 100% pure oxygen. If the player has an injury, the oxygen together with the increase in pressure theoretically pushes the oxygen deeper into the injured area. Recovery time can theoretically be cut in half for the injured surfer. However, insurance will only cover this therapy for crush injuries and a few other indications with negligible applicability to the surfer athlete. Regardless, many professional athletes use it as a supplement to rehabilitation.

Manual therapy is one of the oldest modalities for sports injuries. Manual “reduction” of acute fractures and dislocations should be performed only by qualified professionals. The common theme in first response to most musculoskeletal injuries is traction and immobilization. For overuse injuries of joints and muscles, gentle stretching of the joint capsule and muscles respectively can improve healing times when done properly. Regaining range of motion is probably one of the most important factors after structural healing for return to surf decision-making. 

Osteopathic and chiropractic manipulation have been used often in treating surfing injuries to regain range of motion. They should be done only within a normal physiologic joint range of motion. Most common osteopathic techniques include high-velocity-low-amplitude (HVLA), low-velocity-high-amplitude (LVHA), active myofascial, passive myofascial, “counterstrain” and facilitated positional release. HVLA, like its namesake, uses high-speed adjustments over very small ranges of motion whereas LVHA uses slower adjustments through the full physiologic range of motion. Active and passive myofascial release techniques, facilitated positional release as well as “counterstrain” are used to prevent muscle spasm from interfering with range of motion.

Therapeutic exercise is an important factor in rehabilitating injury. The main purpose of a therapeutic exercise program, like the strength and conditioning program, is to develop strength, endurance, flexibility, proprioception (balance and joint position sense in real time) and integrate that back into surfing specific activity. Do not be discouraged about “gains lost” or setbacks. Consistency, focus and a positive attitude are the most important factors in success.

Neck

All acute injuries of the neck require formal evaluation! Chronic neck overuse injuries typically manifest as muscle strain or spasm. When the neck muscles go into spasm you feel hard, tight muscles in your neck that are very tender to the touch. You have pain when you move your head to either side or when you try to move your head up or down. The important factor is determining whether the pain is from the spinal column or within the muscles that buttress the spinal column. Many surfers suffer chronic neck spasms from the amount of time spent paddling with their necks hyperextended. Contest surfers often seek myofascial realease from TENS, ultrasound, acupuncture, chiropractic or osteopathic manipulation before and after their heats.

Trapezius muscle spasms can cause occipital headaches (at the back of the head) as the muscle of the upper trapezius originates at the base of the skull. The pain may start immediately after injury or may develop insidiously. Symptoms include neck stiffness, dizziness, or unusual sensations, such as burning or a pins-and-needles feeling. “Stingers” may occur with electric-shock type pain running down the arm. These may occur from sternocleidomastoid muscle or trapezius muscle strain but need a doctor’s formal evaluation. Perform the following exercises only if you do not have pain in the bony spine or numbness running down your arm or into your hand.

Upper trapezius stretch: The upper trapezius muscle connects your shoulder to the base of your skull. Sitting or standing, reach behind your head tilt your head until you feel a stretch. Hold for 20 to 30 seconds on each side and perform as often as possible. Stop if there is any sharp pain in the bony areas of the neck.

Scapular squeezes: While sitting or standing with your arms relaxed, squeeze your shoulder blades together as if to “tuck them in your back pockets” and hold for 3 seconds. Do these throughout the day as many times as possible. Alternatively, lay prone on the ground, foam-roller, exercise ball or lean against a suspension strap system such as a TRX and bring arms back as if “flapping your wings” twenty times. Do this with both arms bent (to strengthen the infraspinatus muscle) and straight arms (to strengthen rhomboids and lower trapezius) holding to “scapular squeeze” position for a few seconds each repetition. Another way of visualizing the exercises is to draw alphabet letters with the arms where bent arm scapular squeezes are “W’, straight arm shoulder extensions with hands moving towards hips are “A”, straight arm shoulder flexions with hands moving towards head are “I”, and horizontal shoulder abductions are “T” ultimately spelling “WAIT”. The WAIT acronym can remind you that you are training for surfing and to “wait” for the good waves. As the Duke once said, “be patient, wave come”.

Shoulder Strains from Overuse:

Surfers, like swimmers, are “overhead athletes” which predisposes them to shoulder instability. Worse still, surfers, however, do not have the “body roll” afforded to swimmers in the water and  are even more predisposed to overuse injuries known as “rotator cuff strain” and “multidirectional instability”. Posture problems with rounded shoulders and a forward head posture, known as the “upper crossed syndrome” are also common in surfers and predispose to rotator cuff strains, shoulder instability, biceps tendonitis, neurologic manifestations of thoracic outlet compression syndrome (TOCS) as well as neck spasms which can cause headaches.

 

The structure most vulnerable to strains in the shoulder is the rotator cuff complex. The rotator cuff complex is responsible for shoulder stability and ties the shoulder blades to the arms and collarbones. The scapula (shoulder blade bone) simply rests on the rear rib cage attached by the muscles of serratus anterior. The long head of the biceps and the rotator cuff muscles keep the arm in the shoulder socket at the end (pulling the arm back out of the water) of paddling motion.

 

The triceps is one the main muscles involved in the final acceleration of the arm as it extends during paddling, which is why it often burns at the end of a long, arduous paddle. The biceps then engages to prevent the elbow from going into hyperextension. Shoulder pain in swimmers and surfers primarily occurs during the “pull-through phase” as they must overcome high water resistance in order to propel themselves forward. This pain becomes magnified if there is not full extension of the elbow throughout the stroke (“chicken-wing” strokes) which decreases stroke power and increases risk of injury.

 

Overdeveloped paddling muscles also contribute to impingement and strain. Think of muscle-bound individuals with their shoulders hunched forward. This leads to protracted scapulae, or a chronic posture of the shoulders being rolled forward accompanied by tight chest muscles leading to shoulder impingement. Impingement can be thought of as muscular imbalance of the shoulder. This causes translational movement of the upper arm high into the socket and causing pain by either compression of either the rotator cuff tendon or bursa (lubricating sac) leading to physician diagnoses of “strain” and “bursitis” respectively.

 

The shoulder joint is responsible for internal and external rotation of the arms, horizontal adduction, extension, forward flexion and abduction. Forward flexion and horizontal adduction can be tested by touching thumb of tested extremity to opposite shoulder. External rotation and abduction can be tested by performing the same maneuver behind the head. Extension and internal rotation can be tested by reaching behind your back and touching your thumb to the highest point on the spine. Many will find that their dominant arm cannot reach as high. This is known as “glenohumeral internal rotation deficit” or “GIRD”. GIRD predisposes to higher risk for shoulder injuries in sports.  Posterior capsular and cuff tightness can be addressed by “sleeper stretches”.

 

Athletes who have protracted scapulae for several months often experience associated tightening of the pectoralis minor and short head of the biceps. This leads to an “upper-crossed syndrome” which can be treated by having a friend, therapist or athletic trainer help you assume a supine position (laying on back) on a table and placing a rolled towel or a foam roller under the midline of the back. ently push the shoulders toward the table; the contracted pectoralis minor should relax and stretch. Many athletes report this stretch to be not only painless but also comfortable. Alternatively, you may practice shoulder abductions with the foam roller under your back if you do not have a partner. Try the WAIT acronym with a foam roller placed both longitudinally and perpendicular to the spine behind the chest.

 

Prevent and rehabilitate shoulder overuse injuries with the following exercises over 6 weeks. Pushup type exercises with a suspension trainer (TRX) or on a balance board (such as the IndoBoard) promote shoulder stability by training the shoulder muscles on an unstable surface, much like a surfboard on the water. Those who have suffered prior dislocations, have been diagnosed with multidirectional instability, have pain shooting down the arm or into the neck, have limited range of motion or who have had prior surgery may need a sports physician evaluation prior to performing these rehabilitation exercises.

Biceps stretch: Stand facing a wall (about 6 inches away from the wall). Raise your arm out to your side and place the thumb side of your hand against the wall (palm down). Keep your elbow straight. Rotate your body in the opposite direction of the raised arm until you feel a stretch in your biceps. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

Elastic shoulder external rotation: Stand sideways next to a door. Rest the hand farthest away from the door across your stomach. With that hand grasp tubing that is connected to a doorknob at waist level. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat until it becomes difficult to complete in proper form then progress to the next exercise in the circuit.

Side-lying external rotation: Lying on side with a comfortable weight in hands or standing with a TRX, cable-pulley or fixed elastic band,elbow bent to 90°. Keep your elbow against your side, raise your forearm and hold for 2 seconds. Slowly lower your arm. . Repeat until it becomes difficult to complete in proper form then progress to the next exercise in the circuit. This is a variation of the “W” in the WAIT acronym.

Shoulder Extension: Lying prone with a comfortable weight in hands or standing with a TRX, cable-pulley or fixed elastic band, start with arms flexed at 90 degrees with hands at eye-level. Extend the arms as far as possible so that your palms sweep down across your sides and as far posterior as possible. This is the “A” in the WAIT acronym.   

Scaption: Stand holding a light weight with your arms at your sides and with your elbows straight or standing with a TRX, cable-pulley or fixed elastic band. Slowly raise your arms to eye level. Hold for 2 seconds and lower your arms slowly. Do these as many times as possible in thirty second intervals working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  This is the “I” in the WAIT acronym.

Horizontal abduction: Lie on a table or the edge of a bed face down with one arm hanging down straight to the floor or  stand with a TRX, cable-pulley or fixed elastic band, start with arms flexed at 90 degrees with hands at eye-level. Like scapular squeezes, pinch the shoulder blades together opening arms wide until a stretch is felt in the chest. Do these as many times as possible in thirty second intervals working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute. This is the “T” in the WAIT acronym.

Push-up with a plus: Begin on the floor on your hands and knees. Keep your arms a shoulder width apart. Bend your elbows and lower your body to the floor. Return to the starting position and flare the shoulder blades forward, gaining an extra several inches of “push-up plus”. Do as many as possible until reps become slower and more difficult. Start with a thirty second interval with about 10-15 pushups and train for a goal of 60 per minute. Add hip extensions by kicking up alternate feet like you were duck diving. Also add hip flexion and rotations as if you were brining feet under you for a pop-up. This can help enormously with duck dives and pop-ups. A functional alternative includes a wall push-up-plus with hands at eye level progressing down the wall to a floor version. Do not attempt the floor version first, very few are ready for this variation on hand position.

 

Low back:

The paddling surfer is often in spinal hyperextension, both in the neck and low back. This can lead to low back strain and even a stress reaction of the vertebrae called “spondylolysis”. Clinically, standing on one leg and hyperextending the back will often reproduce the pain of spondylolysis. As spondylolysis progresses, a bilateral stress fracture of the pars may occur in the lumbar spine, causing a slippage of the vertebral column known as spondylolisthesis. Treatment is still conservative unless the slippage angle becomes significant. Conditions where pain is felt more in the bony spine than the surrounding muscles as well as any pain shooting down the legs or into the groin need to be evaluated by a physician.

Hyperextension injury may chronically manifest as hyperlordosis. It is important to correct chronic back hyperextension with correct posture exercises and core muscle strengthening. Most of the time, hyperlordosis is part of a chronic kinetic chain problem called “lower crossed syndrome”. This condition is a postural problem commonly involving hamstring strains anterior knee pain and low back pain. Lower Crossed Syndrome is endemic in western society because most people spend a large percentage of their time sitting, they begin to substitute the low back extensors, thereby producing a "big gut, no butt" scenario (usually aided by poor diet and no exercise). Lifting and walking using primarily the low back extensors cause an increase in biomechanical stress in the lumbar spine producing chronic pain, osteoarthritic degeneration, and disc herniation, which should be evaluated by a physician.

To prevent low back pain and neutralize hyperextension, it is important to have strong abdominal muscles. Perform these exercises most days of the week.

Pelvic tilt: Lie on your back or stand against a wall with your knees slightly bent and your feet flat on the floor. Tighten your abdominal muscles and push your lower back into the floor. Hold this position for 5 seconds, then relax. Do this ten times daily throughout the day.

Piriformis stretch: Lying on your back with both knees bent, rest the ankle of one leg over the opposite knee. Grasp the thigh of the bottom leg and pull that knee toward your chest. You will feel a stretch along the buttocks and possibly along the outside of your hip on the top leg. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

Quadriped Arm/Leg Raises: Get down on your hands and knees. Tighten your abdominal muscles to stiffen your spine. While keeping your abdominals tight, raise one arm and the opposite leg away from you. Do not let the low back fall into an over-arched position. Hold this position for 5 seconds. Lower your arm and leg slowly and alternate sides. Do these as many times as possible in thirty second intervals working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.   

All-fours-to-heels sit: Kneel on the floor on all fours. Your palms should be flat on the floor in front of you and your back should be kept flat. Shift your weight backward and try to sit on your heels. Be sure to keep your back flat. Hold this position for 6 seconds. Return to the starting position. Do this 10 times.

Hip

The hip flexor and extensor muscles are heavily used during surfing pop-ups and turns respectively. It is common for a “lower-crossed” syndrome that causes back pain to overlay into tight but weak hip flexor muscles. These muscles are commonly strained during surfing and could predispose to further injury in the hip-socket leading to impingement, functional limitations and, ultimately, arthritis. Preventative and rehabilitative stretching and exercises are important and can include TRX and IndoBoard variations to add more of a challenge.

You can begin stretching your hip muscles right away by doing the first 2 exercises. Make sure you only feel a mild discomfort when stretching and not a sharp pain. You may do the last 3 exercises when the pain is gone.

Hip flexor stretch: Kneel, then put your one leg forward, with the foot resting flat on the floor. From this position, tighten your stomach muscles, flatten your lower back and lean your hips forward slightly until you feel a stretch at the front of your hip. Try to keep your body upright as you do this. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

 

Quadriceps stretch: Stand an arm's length away from the wall with your injured leg farthest from the wall. Facing straight ahead, brace yourself by keeping one hand against the wall. With your other hand, grasp the ankle of your injured leg and pull your heel toward your buttocks. Don't arch or twist your back. Keep your knees together. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

 

Straight leg raise: Lie on your back with your legs straight out in front of you. Bend the knee on your uninjured side and place the foot flat on the floor. Tighten the thigh muscle of the other leg and lift it about 8 inches off the floor, keeping the thigh muscle tight throughout the range of motion. Do not over arch the back. Progress to lifting the leg higher without compensating or altering your posture. Slowly lower your leg back down to the floor. Do these as many times as possible in thirty second intervals working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  

Resisted hip flexion: Stand facing away from a door. Tie a loop in one end of a piece of elastic tubing and put it around one ankle. Tie a knot in the other end of the tubing and shut the knot in the door near the bottom. Tighten up the front of your thigh muscle and bring your leg forward, keeping your knee straight. Do these as many times as possible in thirty second intervals working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute. Alternatively, “mountain climbers” or “treadmills” can be done with the TRX or on the ground in plank position to strengthen the hip flexors without elastic tubing.

 

Hip Knots

As more surfers are in a prone paddling position with short-board surfing, hip knots or “collagenomas” may arise and become quite disturbing to a surfer not acquainted with fluid filled lumps on the anterior bony pelvic protuberances. This is a unique surfing overuse injury. Some women pros display impressive sized knots on their anterior superior iliac spines (hip bones). Currently there is no treatment beyond icing and gentle stretching as drainage has not been shown to be helpful.

 

 

Knee

Certain exercises associated with leg muscle development have been observed by experience to be counterproductive to athletic performance yet they are still recommended by “the pros”. These exercises, such as treadmill running, deep-squats and leg extensions have been quite popular over the years and will likely be difficult to habituate out of. They are also the most common cause of worsening knee arthritis and anterior knee pain (“runner’s knee”).  Many surfers suffer from overuse injuries and arthritis in the knees, despite the fact that less than 5% of surfing is done while standing up by most accounts.

 

Prolonged sitting on the surfboard with the insides of the knees in contact with the board can lead to numbness and tingling of the inside of the knees called “saphenous neuropathy” that should improve within a few days to weeks. If it does not improve, it should be evaluated by a physician.

Knee Knots

Board contact from knee paddling can also lead to the development of “surfer’s knots” on the inside of knees and feet. These benign masses are filled with a gelatinous “collagen” type material and diminish with time away from the chronic friction between body and surfboard. If they are exquisitely tender, demonstrate red streaking or are associated with fevers they should be evaluated by a physician.

Anterior knee pain syndrome can be relieved by avoiding activities that make symptoms worse like avoiding paddling, sitting or kneeling in the bent-knee position for long periods of time. Knee paddling can also contribute to this anterior knee pain. Biking is one of the best aerobic replacements for treadmill running as well as rehabilitation for anterior knee pain and knee osteoarthritis pain. Adjust a bicycle or exercise bike so that the resistance is not too great and the seat is at an appropriate height. The rider should be able to spin the pedals of an exercise bike without shifting weight from side to side, and the legs should not be fully extended at the lowest part of the pedal stroke. Avoid bent-knee exercises, such as squats, deep knee bends, or leg extensions where the knee is bent greater than 90 degrees.

Sometimes overly bent knees cannot be avoided. When riding a fast tube backside, the “pig-dog” position, popularized by Dane Kealoha where the surfer crouches low over a bent front knee, back leg extending back, outside hand holding onto the outside rail, and inside arm extended upwards touching the face of the wave as a guide will compress the patella (kneecap) of the bent knee against the thighbone. Landing airs causes immense stress on the knee joint and ligaments. Even if the ligaments and cartilage are not torn, a small amount of swelling or minor muscle strain can cause pain at the back of the knee. This needs simple rest, ice, compression and rehabilitation exercises unless the knee is grossly swollen or unstable, in which case it should be seen by a doctor.

When associated with plantar fasciitis (heel pain), shin splints and low back pain, the knee alignment may need to be evaluated by a sports physician to rule out flat feet, patellar mal-alignment or a combination called “pronator distortion syndrome”. Rehabilitation exercises help the body find a way to adjust from knee hyperflexion to hip flexion and abduction. Remember, any instability, catching or locking of knee should be evaluated by a sports physician.

Strong yet limber quadriceps and hamstring muscles buttress the knee joint and help prevent and recover from injuries. Try the following prevention and rehabilitation program:

Standing hamstring stretch: Place the heel of your leg on a stool about 15 inches high. Keep your knee straight. Lean forward, bending at the hips until you feel a mild stretch in the back of your thigh. Make sure you do not roll your shoulders and bend at the waist with a neutral spine when doing this or you will stretch your lower back instead of your leg. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

Side-lying leg lift: Lying on your uninjured side, tighten the front thigh muscles on your top leg and lift that leg 8 to 10 inches away from the other leg. Keep the leg straight and lower slowly. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  A TRX may be used to enhance hip and knee stability.

Straight leg raise: Lie on your back with your legs straight out in front of you. Bend the knee on your uninjured side and place the foot flat on the floor. Tighten the thigh muscle of the other leg and lift it about 8 inches off the floor, keeping the thigh muscle tight throughout. Slowly lower your leg back down to the floor. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  

Wall squat with a ball or TRX squat: Stand with your back, shoulders, and head against a wall and look straight ahead. Keep your shoulders relaxed and your feet 2 feet away from the wall and a shoulder's width apart. Place a soccer or basketball-sized ball behind your back if doing a wall squat. Keeping your back upright, slowly squat down to a position where a 90-degree angle at the knees and hips is created. Your thighs will be parallel to the floor at this point. Hold this position for 10 seconds and then slowly extend to standing position. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  

Standing calf stretch: Facing a wall, put your hands against the wall at about eye level. Keep one leg back with the heel on the floor, and the other leg forward. Turn your back foot slightly inward (as if you were pigeon-toed) as you slowly lean into the wall until you feel a stretch in the back of your calf. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

 

Iliotibial band stretch, Side-bending: Cross one leg in front of the other leg and lean in the opposite direction from the front leg. Reach the arm on the side of the back leg over your head while you do this. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

 

Elbow:

 

Elbow pain is common during paddling and usually manifests itself on the inside section. “Surfer’s elbow” is elbow pain in the origin of flexor carpi ulnaris (a muscle responsible for flexing the wrist) related to repetitive paddling and pop-up maneuvering. Anterior elbow pain is caused by overuse of this muscle in a position where the biceps muscle is not or is only insufficiently functioning, which occurs with flexion of the elbow, particularly during long stalls in a barreling wave or during layback snaps. This may predispose towards tendinitis from heavy eccentric flexion forces about the elbow when done repeatedly. The ulnar nerve can also be inflamed from its irritation or injury causing burning pain shooting into the tips of the ring and small finger. Anterior elbow pain in the “crook” of the elbow heralds distal biceps and brachialis tendonitis which may arise from frequent stalling in heavy wave action (too much tube riding). This may be an additional “unique surfing injury”.

Rehabilitation exercises for these elbow injuries involve stretching and strengthening the flexor and extensor as well as the pronator and supinator muscles of the wrist and forearm. Do the stretching exercises right away. Do the strengthening exercises when stretching is nearly painless. Stretching exercises include pronation and supination stretches. Pronation and supination of the forearm involves bending the elbow to 90°, turning your palm upward and holding for 5 seconds. Slowly turn your palm downward and hold for 5 seconds. Make sure you keep your elbow at your side and bent 90° throughout this exercise. Do these as many times as possible until proper form cannot be maintained.

Strengthening exercises include wrist flexion and extension as well as forearm internal and external rotation holding an elastic band in your hand anchored on something (possibly your foot when performing in conjunction with a hamstring stretch). With palm down, bend your wrist upward then downward and twist left and right as if opening the door. The stretch of the elastic tubing will provide the resistance. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  .

Tubing exercise for external rotation involves resting the hand of your injured side against your stomach. With that hand grasp tubing that is connected to a doorknob or other object at waist level. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  .

 

Ribs

The 12 ribs on each side of your chest may be bruised, strained, broken, or separated during surfing. With overuse, ribs may tear away from the cartilage that attaches them to the breastbone. This tearing away from the cartilage is called a costochondral separation. A costochondral separation may occur from trauma, when you land hard on your feet, or even when you pop-up on your board. A rib injury causes pain and tenderness over the place of injury. You may have pain when you breathe, move, laugh, or cough. To help your injury heal, rest and ice massage the injured rib until the ice cubes melt every 3 to 4 hours for 2 to 3 days or until the pain goes away. Bruised ribs and a costochondral separation usually take 3 to 4 weeks to heal. Broken ribs take 6 to 8 weeks to heal and should be evaluated by a physician. You may surf if you can do so without pain in your ribs and without pain when you breathe.

Surfer's rib is an isolated first-rib fracture and occurs in surfers who perform the lay-back maneuver excessively. It may also be associated with thoracic outlet syndrome. Thoracic outlet compression syndrome (TOCS) may manifest as a chronic dull or burning pain and weakness in the arm. Thoracic outlet syndrome is painful arm condition that may also be confused with brachial neuritis or nerve entrapment syndromes that also cause shoulder and arm pain.

Trauma, inflammation, wrong posture or dynamic demands of upper extremity predispose to the onset of TOCS. Try the following exercises to prevent TOCS symptoms. If they persist, see your doctor.

 

Scalene stretch: This stretches the neck muscles that attach to your ribs. Sitting in an upright position, clasp both hands behind your back, lower your left shoulder, and tilt your head toward the right. Hold this position for 15 to 30 seconds and then come back to the starting position. Lower your right shoulder and tilt your head toward the left until you feel a stretch. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch.

 

Pectoralis stretch: Stand in a doorway or corner with both arms on the wall slightly above your head. Slowly lean forward until you feel a stretch in the front of your shoulders. Hold 15-30 seconds, contracting the muscle briefly for about two seconds mid-stretch to facilitate muscular biofeedback in the stretch. Alternatively, perform this with a TRX.

 

Scapular squeeze: While sitting or standing with your arms relaxed, squeeze your shoulder blades together as if to “tuck them in your back pockets” and hold for 3 seconds. Do these throughout the day as many times as possible.

 

Thoracic extension: While sitting in a chair or preferably on an exercise ball, clasp both arms behind your head. Gently arch backward and look up toward the ceiling. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute. Avoid jerky movements.

 

Rowing exercise: Attach a TRX or tie a piece of elastic tubing around an immovable object, grasping the ends of that tubing in each hand. Keep your forearms vertical and your elbows at shoulder level and bent to 90 degrees. Pull backward on the band and squeeze your shoulder blades together. Do these as many times as possible until proper form cannot be maintained working from fifteen repetitions per 30 seconds toward a goal of sixty repetitions per minute.  

 

Mid-trap exercise: Lie on your stomach on a firm surface and place a folded pillow underneath your chest. Place your arms out straight to your sides with your elbows straight and thumbs toward the ceiling. Slowly raise your arms toward the ceiling as you squeeze your shoulder blades together. Lower slowly. Do 3 sets of 15. Alternatively use an Indo Board or TRX for this exercise

 

 

 

 

Chest and Rib Knots

 

As more surfers are in a prone paddling position with short-board surfing, chest knots or “collagenomas” may arise and become quite disturbing to a surfer not acquainted with fluid filled lumps on the ribs and costal cartilage. This is a unique surfing overuse injury. Some pros display impressive sized knots on the ribs and sternum . Currently there is no treatment beyond icing and gentle stretching as drainage has not been shown to be helpful.