Surfboard riders are prone to a multitude of acute and chronic conditions (Table 20.1).

Several authors have presented retrospective studies on the frequency and type of injuries incurred by surfers. Lowden et al. published one of the first studies on the prevalence of injuries among 346 Australian surfers which required either medical attention or days lost from surfing [3]. They reported that lacerations were most frequent, representing 41 % of all injuries. Most lacerations were to the head, mainly to the skull, with lower extremity lacerations next most frequent. The second most common injury type was dislocations, sprains, and strains which represented 35 % of all injuries. Other injuries included skull and body fractures, contusions, and tympanic membrane perforations. Overall, 3.5 injuries per 1000 surfing days were reported in their study.

In 2002, Nathanson published a larger study of 1348 surfboard riders [1]. They also found lacerations to be the most common injury, but with head and neck lacerations to be equally as prevalent as lower extremity ones. Contusions, sprains, and fractures were also seen. The majority of contusions affected the trunk and lower extremity. Sprains were most reported in the lower extremity, with knee injuries most often seen. The majority of fractures reported by Nathanson et al. were to the head and neck. Of note, both Lowden and Nathanson found a higher level of injury severity in more advanced surfers, who often engage larger waves in more extreme conditions (Fig. 20.6).

The large majority of injuries reported in both studies were from contact with a surfboard, usually the rider’s own board. The rail and fins of the board accounted for most of the injuries seen. The seafloor is another common source for injury, responsible for 17 % of injuries in the Nathanson study. Surfing over coral reefs versus sand is a significant risk for sea floor injuries [1] (Fig. 20.7).

Additional risks involved with surfing include injury leading to either drowning or hypothermia should the surfer not be able to safely return to shore. Lacerations have the added potential of becoming infected with seaborne organisms and should be treated for Vibrio and Pseudomonas, along with the more common Staphylococcus and Streptococcus.

Nathanson published another study in 2007 on injuries during 16,657 surfer heats observed over 32 surfing competitions worldwide from 1999 to 2005 [4]. They found an injury rate of 13 per 1000 h of competitive surfing. Professional competitions had higher rates of injury in comparison to amateur competitions; however, professional contests were held in larger surf, were longer in duration, and occurred more often over a hard bottom, as opposed to sand. Sprains and strains were most commonly seen, followed by lacerations, contusions, and fractures. The lower extremity was the most injured location, with knee sprain/strain being the most common injury pattern overall. The majority of injuries were due to impact with the surfboard, and most injuries occurred during an unsuccessful takeoff, followed by turning maneuvers.

Preventive safety measures can help reduce the frequency and severity of injury. Surfing helmets are available and their widespread use could help reduce the number of head lacerations and fractures [5]. Nathanson, however, reported that only 8 % of surfers in their survey used helmets [1]. Rubber guards on the board’s nose and soft-edged or rubber-guarded fins would also help reduce the number of lacerations and are thought not to alter surfboard dynamics to any appreciable degree. Their use as reported by Nathanson is limited, with 40 % of surfers reported using nose guards and only 5 % of surfers having soft-edged fins [1]. Protective eyewear specifically designed for surfing is available from several manufacturers and may afford both protection from UV rays and orbital trauma.

The use of a board leash in preventing injury is controversial. Leashes do seem to have reduced the number of accidents involving loose boards hitting other surfers. Leashes also provide the downed surfer with access to a floatation device in the event of serious injury. But by keeping the board in close proximity to the surfer, leashes may increase the risk of board-induced injury. In addition, board recoil from the leash is another mechanism for injury to the surfer. Two articles of surfboard-related ocular trauma implicate the board nose as the common mechanism of injury, with Kim et al., implicating leash recoil as one causative factor [6, 7]. Leashes are sold in varying lengths. Longer leashes may decrease recoil injury, with the consequence of increased risk of injury to others.

A recent addition to potential injury associated with surfing has been coined surfer’s myelopathy by Thompson et al., who reported nine cases occurring between 1998 and 2003 in Hawaii [8]. Since then, several case reports and case series have been published, describing very characteristic clinical presentations and features among patients with surfer’s myelopathy [9–18]. It seems to affect first-time surfers or those learning the sport. It appears to be a nontraumatic paraparesis/paraplegia that may be associated with hyperextension of the lower thoracic, upper lumbar segments in an untrained surfer. No injury was noted during surfing, but most patients complained of mild mid- to low back pain, lower extremity weakness, and urinary retention. A retrospective review of MR findings in 23 cases of surfer’s myelopathy by Nakamoto et al. demonstrated central T2 hyperintense signal abnormalities in the spinal cord extending from the midthoracic region to the conus in all cases. These findings were associated with cord expansion and conus enlargement, all seen within 24 h of symptoms onset. However, MR findings did not correlate with symptom severity or clinical improvement [19]. Although most patients achieved significant improvement or resolution, several cases of complete paraplegia have been noted. The pathophysiology is possibly due to a secondary ischemic event from hyperextension and spinal cord traction, resulting in spinal cord injury and the abnormal signal findings of the lower thoracic/upper lumbar segments of the spinal cord seen on MRI. While not enough is known of this disorder to make definitive recommendations on prevention, swimming and surfboard paddling for endurance and strength gains as well as flexibility training may reduce the incidence of this malady, particularly since it does not appear to affect experienced surfers.

Surfing like most other sports is not immune to overuse injuries. The overhead nature of paddling is similar to swimming. Shoulder impingement syndrome, acromioclavicular arthrosis, and rotator cuff strains are common to surfers. Treatment is similar to that seen in other sports and includes activity modification, rotator cuff/periscapular strengthening, injections, and arthroscopic surgery for refractory cases or complete cuff tears. Prevention is geared toward a strengthening and consistent paddling regimen to maintain adequate strength and fitness [2].

Neck and lower back pain are common complaints of surfers. Degenerative disk and joint disease account for a fair amount of these complaints, particularly among aging surfers. Surfing has been implicated in a number of cases of spondylolysis and spondylolisthesis due to its repetitive hyperextension of the lumbar spine [2].

Spine trauma in the cervical spine is of particular concern because of the potential for central cord syndrome (CCS). Over 50 % of these injuries occur in older surfers particularly those with preexisting spondylosis [20]. The mechanism of injury was similar with nearly all of the injuries caused by hitting the ocean floor (75 %) resulting in neck hyperextension [21]. Injuries usually occur in the lower cervical spine and can result in burst fractures and complete spinal cord injuries.