Kelly gets a helping hand from the medical staff at the Pipe Masters
Introduction & Background
To date, there is a lack of published documentation regarding injuries sustained and treated during professional surfing events. Calculating an injury rate for recreational surfers is difficult because the nature of recreational surfing makes it challenging to determine the population at-risk.1 To overcome this obstacle we developed an injury surveillance tool, to collect data during the 2013 Vans Triple Crown (VTC) and HIC events. The objective of this data collection form, the SURF form was to both observe injury patterns and trends as well as to assess treatment administered by the medical professionals on site. It will also ideally serve as a foundation for future injury report forms for the sport, which will continuously be updated and revised to portray a more comprehensive overview of occurrence and treatment of injuries in the sport of surfing.
We expected to observe several trends when reviewing the data due to the nature of the sport. The events included in this report took place during the winter in Hawaii. During this time the waves are at their peak intensity. Not only is the size of the wave face a factor, but also the bottom contour and weather conditions. Increased wave height and surfing over rock or reef floor have been shown to increase the risk of injury.2,3 The left break at Pipeline, for example, breaks over a shallow and dangerous reef. Most acute injuries, however, are caused by contact with the actual surfboard.1
Surfers are prone to certain chronic or overuse conditions due to the biomechanical demands of the sport. Previous literature has found a high incidence of sprains and strains in the shoulder and back.4 This is postulated to occur as a result of stress placed on both of these locations during paddling. The lumbar spine is placed in a constant state of extension to compensate for the limited range of motion in the upper thoracic spine and possibly further limited range of motion at the glenohumeral joint. This can lead to stress on the vertebral column and discs that can present with pain over time or after activity.
Repetitive motion at the glenohumeral joint leads to extreme muscle and capsular tightness that limits shoulder range of motion (ROM), particularly external rotation and abduction. This in turn affects the scapular-thoracic rhythm and decreases the mobility of the thoracic spine in side bending and rotation, leading to shear forces imposed upon the structures of the lumbar spine. Limited scapular stability and thoracic mobility put the shoulders in an anatomical position that makes it difficult to achieve adequate range of motion and power production. These factors also contribute to stress and injury in the glenohumeral joint.5
Muscle imbalance is also thought to contribute to chronic injuries of the back and shoulder. This occurs when the demands placed on the primary muscle groups required for surfing are not complimented by an adequate strength and conditioning program of opposing muscle groups. Because of this, we expected to observe a dominant amount of chronic/overuse injuries to these areas in the injury report data.
Materials & Methods
All medical professionals assisting in the VTC and HIC professional contests were required to enter information relating to treatment used in the injury reporting Excel spreadsheet. Providers specified the patient name, age, gender, competition status, injuries from the day, total injuries, mechanism of injury, the area of board causing injury, protective gear used and treatment administered. Information regarding the weather and water conditions was also noted, including wave size and bottom type. Conditions, however, often changed throughout the day. These changes were not accounted for.
The graphs and summaries presented in this report demonstrate the injuries sustained by surfers during the 2013 season. All injuries accounted for were sustained by participants of the contests. Some injuries may have been sustained at a different event or during a free surf session, however the patient was a registered participant of the HIC pro or the Vans Triple Crown and received assessment and/or treatment from the participating medical staff.
The file was updated throughout the competition and included data for all patients treated including non-contestants. The following breakdown for each contest will include only data from injuries to registered contest participants. The breakdown for treatments administered, however, will include by surfers and non-surfers (including staff and spectators).
When extracting data from the injury report spreadsheet, acute injuries were defined as those suffered during competition in a single event and chronic/overuse injuries were defined as those occurring over time or an injury not suffered during competition, but still receiving treatment. Because of issues with complete reporting, however, these definitions had to be widened and adapted, which is elaborated on in the discussion section.
Results
HIC Pro
The HIC Pro had an average of 6-14 foot wave faces and 1,198 waves were surfed. A total of 39 chronic/overuse and 20 acute injuries were treated during this competition period. Of the 59 injuries treated, 8 were sustained during the competition. The injury rate for the HIC Pro was calculated to be 6.6 injuries per 1,000 waves surfed. The shoulder (55%) was the most commonly treated site for both overuse and acute injuries followed by the back (18%).
Reef Hawaiian Pro
The Reef Hawaiian Pro took place over a 13-day period with 2-10 foot waves. A total of 27 chronic/overuse injuries and 11 acute injuries were treated during this competition period. Of the 38 total injuries treated during this time, 1 was sustained during the competition and 620 waves were surfed. The injury rate for the Reef Hawaiian Pro was calculated to be 1.6 injuries per 1,000 waves surfed. The cervical spine was the most prevalent area treated for acute injuries at 28% and the back and neck (including the cervical, thoracic and lumbar spines) was the most common area treated for overuse injuries with a prevalence of 66%.
Vans World Cup—Sunset Beach
The Vans World Cup took place over an 8-day period with 3-15 foot waves. A total of 16 chronic/overuse injuries and 19 acute injuries were treated during the competition period. Of the 35 injuries treated, 7 were sustained during the competition and 1351 waves were surfed. The injury rate for the Vans World Cup was calculated to be 5.2 injuries per 1000 waves surfed. The shoulder was, again, the most commonly treated area for acute injuries during the Vans World Cup. The back was the most commonly treated area for overuse injuries at 40% with half of those being injuries to the lumbar region.
Pipe Masters
The Billabong Pipe Masters took place over a 7-day period with 10-12+ foot waves. A total of 8 acute injuries and 11 chronic/overuse injuries were treated during this competition period. Of the 19 injuries treated, 5 were sustained during this competition and 503 waves were surfed. The injury rate for the Pipe Masters was calculated to be 9.9 injuries per 1000 waves surfed. The knee was the most frequent site of treatment for acute injuries at 30%, followed by the ear at 20%. The shoulder was the most frequent site of treatment for chronic/overuse injuries, accounting for 37% of injuries.
Triple Crown Events and HIC Overview
Table 1. Number of acute and chronic/overuse injuries by body part.
A total of 93 chronic/overuse injuries and 60 acute injuries were treated during the Triple Crown and HIC events. Of the 153 injuries treated during this period, 21 were sustained during competition. During the four contests, a total of 3,672 waves were surfed in 211 heats. The overall injury rate for injuries suffered during competition was calculated to be 5.7 injuries per 1000 waves surfed or 99.5 injuries per 1000 surfer heats. This statistic is higher than a previous larger prospective study, which reported 8.7 injuries per 1000 surfer heats at professional contests.1
This means that only 14% of injuries treated were sustained during competition with an average of 4.2 injuries occurring per competition. Overall, the cervical and lumbar spines were the most commonly treated areas for acute injuries. The back and shoulder were the mostly commonly treated areas for overuse injuries. Of the 94 chronic/overuse injuries that received treatment, shoulder injuries had a prevalence of 19% and back and neck injuries (including the cervical, thoracic and lumbar spine) had a prevalence of 49%. Together the two regions accounted for over two-thirds of all injuries treated.
Treatments Administered
The below tables indicate the various treatment methods administered by licensed professionals to competitors, spectators/bystanders and staff across all four contests. The information was extracted from a “treatments” column on the injury report form. Some conditions received multiple treatments, which were determined by the provider attending to the patient.
Table 2. Treatment methods administered to acute injuries.
Table 3. Treatments administered to lacerations (sutures/non-sutures), general illness and staph infection.
Table 3. Treatments administered to chronic/overuse injuries.
The above table outlines all treatment given (competitors and non-competitors) during the Triple Crown and HIC events. The most common treatment for chronic conditions was Soft Tissue Mobilization/Manual Therapy/Joint Mobilization, followed by massage, OMT and physical therapy. Lacerations were either treated with stitches or wound care, depending on the severity, which was assessed on site. Acute injuries were generally treated with an MD evaluation and prescription followed by Soft Tissue Mobilization/Manual Therapy/Joint Mobilization.
Of the acute injuries suffered by participants during all four events, only two were severe medical emergencies. Neither required immediate transportation to a hospital for advanced trauma or life support. The first was a dislocated shoulder and the second was a perforated eardrum. Both occurred during the Pipe Master event and were managed appropriately by licensed medical professionals.
Discussion
This injury report demonstrates that the predominance of injuries evaluated and treated are minor to moderate chronic/overuse injuries that do not prevent participants from competition. Many of the overuse exposures accounted for are from returning patients that have sustained nagging injuries and are asked to check in to monitor their progression. In agreement with our expectations, we noticed that the majority of chronic or overuse injuries treated were related to the back or shoulder. This information can be used as a preventative tool for athletes and trainers when establishing a training protocol.
This report, however, was not without limitations. A major limitation for this study was an issue on incomplete injury report forms. If the provider who attended to the patient could not recall the injury and treatment, the patient was not included in the study. Fortunately, the occurrence of this was limited, but should still be noted and taken into consideration when analyzing the results of this report. Another limitation was the discrepancy between number of acute injuries and number of injuries suffered during competition. It was our goal to ideally be able to define an acute injury as one suffered at the time of competition and a chronic/overuse injury to be defined as either an injury not suffered from a single event and/or an injury not suffered during the competition, but still requiring continued treatment. The incomplete injury report forms, however, made this difficult. We, rather, decided to classify injuries based on a combination of complete report forms and the description of the injury. This has been taken into account as a major issue to be addressed for injury reporting at future contests. While we are confident that all injuries suffered during competition are accounted for and labeled as such, the issue of incomplete reporting led us to include those injuries that were determined acute by description, but were not reported as being suffered during competition or not to avoid inadvertent data manipulation. Future injury report forms need to be updated to reflect this issue and achieve a higher compliance rate. Additionally, future studies may want to consider defining acute injuries according to a specific time frame and subsequently subcategorize those suffered during competition to achieve a more thorough reflection of injury in the sport.
The longevity of time participants spend in Hawaii allows them to establish a relationship with medical professionals in which they feel comfortable to reach out and get the medical attention they need to heal their injuries. Oftentimes the athletes participating in the contest do not have access to medical or rehabilitation professionals for multiple reasons, i.e. travel, financial etc. During all events medical issues are addressed and care is provided, including prescriptions for illness or infections, stitches for lacerations, rehabilitation methods including soft tissue mobilization, joint mobilization, therapeutic exercise prescription for acute and chronic injuries and evaluation and management. It is truly a service that the medical team provides care for not only the participants of the HIC Pro and Triple Crown, but the staff and traveling families as well.
Conclusion
The actual number of injuries suffered during the Triple Crown and HIC events was relatively small when compared to the number of injuries treated. A lack of complete data, however, makes it difficult to make any assertions with certainty. Treatment administered varied based on the condition, but the given data suggests that the medical professionals present evaluated and treated injuries in an appropriate manner. Furthermore, the shoulder and the back were the most common sites of chronic or overuse injury, which could be important when developing a strength and conditioning or injury prevention program for the sport. Acute injuries were more unpredictable, which was expected due to the nature of the sport. Overall, the injury report form provided useful information and should be implemented in some form in future contests to help advance sports medicine practices in the sport of surfing.
References
1. Nathanson, Andrew, et al. “Competitive Surfing Injuries A Prospective Study of Surfing-Related Injuries Among Contest Surfers.” The American journal of sports medicine 35.1 (2007): 113-117.
2. Nathanson, Andrew, Philip Haynes, and Daniel Galanis. “Surfing injuries.” The American journal of emergency medicine 20.3 (2002): 155-160.
3. Pikora, Terri J., Rebecca Braham, and Christina Mills. “The epidemiology of injury among surfers, kite surfers and personal watercraft riders: wind and waves.” (2012): 80-97.
4. Lowdon, B. J., N. A. Pateman, and A. J. Pitman. “Surfboard-riding injuries.”The Medical Journal of Australia 2.12 (1982): 613-616.
5. Strunce, Joseph B., et al. “The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain.” Journal of Manual & Manipulative Therapy 17.4 (2009): 230-236.
Authors:
Leland Dao, DO
Lauren Reinert MS, ATC, CSCS
Alycia Carrillo, BA