Surfing Injuries

Fig. 7.1

(a) A floater is a maneuver where the surfer rides the breaking wave on top of it. Tel-Aviv beach. Surfer: Adi Gluska, (Photo: Roger Sharp). (b) A surfer uses a “cut-back” maneuver to get back to the lip of the wave, where most of its energy is concentrated. The Maldives Islands. Surfer: Adi Gluska, (Photo: Navi)

Demographics

Estimates as to the number of surfers worldwide vary greatly. In 2002, Surfing Australia estimated that there were 17 million people who had surfed at least once in the last year, and in 2006 the International Surfing Association put that number at 23 million [3]. A survey by the Outdoor Foundation in 2009 estimated that 2.4 million people in the USA surfed at least once in the last year, with an average of 22 outings per year per surfer. They also found that 23 % were first-time participants, suggesting a continuing high growth rate [4].

Approximately 10 % of surfers are women, and it appears that the average age of surfers in the USA has been increasing over the last decade from the late 20s in 2000 to the mid-30s in 2009 [5, 6].

Surfing Equipment

Surfing, SUP, and Tow-In

Part of surfing’s beauty lies in its simplicity. The only necessities are a board and a bathing suit, and the waves are free of charge. Though surfboards vary greatly in size and shape depending on the surfer’s weight, ability, and riding style, the basic design and construction of most boards is similar; a foam “blank” is cut to shape and then sheathed in a fiberglass skin to create a lightweight but rigid structure. Polyurethane blanks are strengthened by a longitudinal, glued-in wooden stringer and covered with fiberglass which is saturated with polyester resin, while a more modern technique utilizes a polystyrene foam core and fiberglass saturated with a more durable epoxy resin. Anywhere from one to five fins (skegs) are placed at the tail end of the bottom of the board to give directional stability. The board’s deck is coated with nonskid wax or foam pad to provide traction.

Most surfers utilize a leash (tether, leg rope) to prevent their board from being swept shoreward by the waves after a wipeout, thus averting a potentially long swim back to shore. Leashes are made of a thin flexible urethane cord affixed to the tail end of the surfboard’s deck at one end and to the rider’s ankle via a Velcro strap on the other.

The vast array of surfboard designs can be broken down into four broad categories: longboards, shortboards, SUP boards, and tow-in boards. The overall size (>2.5 M) of longboards makes them relatively stable and efficient to paddle. These characteristics make it easier to catch and ride waves, so these boards are well suited to beginners and favor a graceful, fluid riding style. Shortboards (<2.2 M) are much more maneuverable than longboards and are better suited for steeper, faster breaking waves. SUP boards are thicker, wider, and usually longer than longboards and provide a stable platform on which to stand. SUP boards designed for flat water paddling and racing are up to 5 m in length and relatively narrow, whereas those designed for riding waves tend to be shorter and wider. The single-bladed paddles used to propel an SUP board have a shaft that is approximately shoulder height and are made from rigid, lightweight materials such as carbon fiber. Lastly, tow-in boards, like water skis, are narrow, roughly 2 m in length, and equipped with foot straps so the rider can maintain control when going over chop at high speeds. These boards are heavily built to withstand the forces of the huge waves in which they are ridden and often weighted to prevent them from becoming airborne.

Bodyboarding and Bodysurfing

Bodyboards are used to ride waves in a prone position, with the rider wearing swim fins to aid in propulsion. These short (1.2 m), light, relatively inexpensive boards are made of closed-cell foam and lack fins, so collisions with one’s board are relatively harmless. Riding waves is easier than on a surfboard because the rider need not hop up into a standing position, so they are favored by beginners and young children. That being said, there is a cadre of hard-charging expert bodyboarders who ride some of the most technically challenging waves in the world.

Bodysurfing is perhaps the purest and likely the oldest form of surfing. When a meter or so in front of a breaking wave, the bodysurfer swims rapidly shoreward (aided by a short pair of swim fins) and utilizes their elongated body as a planing surface to ride the wave. Experienced bodysurfers extend an arm overhead to create a longer planing surface and increase speed and control.

Wetsuits

Modern neoprene wetsuits are remarkably lightweight, warm, and flexible. They vary in thickness and body coverage according to the water temperature in which they are intended to be used. Advances in wetsuit technology have allowed surfing to be a year-round sport and have expanded the sport’s range to include Canada, Northern Europe, as well as the extreme southern latitudes.

In tropical climates, surfers often forgo a wetsuit in favor of a thin nylon “rash guard” which protects against chafe between board and rider and also functions as a sunblock. At the other end of the temperature spectrum, a full-body, hooded, 5–6-mm thick wetsuit, combined with neoprene booties and gloves, can keep a surfer warm for well over an hour in seawater approaching the freezing point. Wetsuits heated by means of a battery pack are now commercially available.

Injury Rates and Risk Factors

Despite its reputation as a dangerous activity, surfing has been found to be relatively safe as compared to more traditional sports. Lowdon’s 1983 mail administered survey-based study of self-reported injuries among members of an Australian surfing club found 3.5 “moderate to severe” injuries (those that resulted in lost days of surfing or required medical care) per 1,000 surfing days [7]. More recently, Taylor’s 2004 interviewer-administered survey found an injury rate of 2.2 significant injuries per 1,000 surfing days among a convenience sample of surfers at beaches in Victoria, Australia [8].

Lowdon’s 1982 interviewer-administered survey of 79 professional surfers found the rate of moderate to severe injuries during practice or competition in that group to be 4 per 1,000 surfing days. He concluded that surfing was safer than professional rugby (55 injuries per 1,000 days), downhill skiing (6 injuries per 1,000 days), and American high school football (5.9 injuries per day) but riskier than men’s gymnastics (1.8 injuries per 1,000 days) [9]. Over the period 1999–2005, Nathanson et al. prospectively studied acute injuries sustained at 32 professional and amateur surfing contests worldwide. His group found that the rate of “significant injury” (those that resulted in lost days of competition or required acute medical care) was 6.6 per 1,000 hours of competition. This injury rate compares favorably to those found from studies of American collegiate football (33 per 1,000 hours), soccer (18 per 1,000 hours), and basketball (9 per 1,000 hours) in which similar methods of data collection and definition of injury were used [10].

A logistic regression analysis of Nathanson’s data revealed that the relative risk of injury among contest surfers was greater when surfing in wave heights that were overhead or bigger relative to smaller waves (odds ratio 2.4), and that risk of injury was increased when surfing over a rock or reef bottom as compared to a sand bottom (odds ratio 2.6). In a study whose population were predominantly recreational surfers responding to a web-based survey, Nathanson found that the odds-ratios for significant injuries increased with age as well as with self-rated ability, and that there was no difference in injury rates between male and female surfers [10, 11].

Surfing Fatalities

The fatality rate for surfing is unknown. The Hawaii Department of Injury Prevention and Control reviewed the autopsy reports of 306 drowning deaths in the state of Hawaii from 1993 to 1997 and found that bodyboarders and surfers accounted for 17 of 238 ocean-related drownings [12]. During this 5-year period, there were also two fatal shark attacks on surfers. Though surfing is hugely popular in Hawaii year round, there are no reliable estimates of the number of surfers in the state.

An unpublished review of newspaper reports (by this author) searching the Nexus/Lexus database from 1984 to 1998 using the key words “surfer,” “surfing,” “death,” “drowning,” and “fatality” found accounts of 95 surfing-related fatalities in which cause of death was reported (though not confirmed). Drowning was stated to be the cause of death in 63 cases. Factors reported to be contributing to these drownings were concussions (11), seizures (4), and leash entanglement (4). Shark attacks were responsible for 12 deaths, lightning strikes for 8, and lacerations from surfboard fins for 2 others.

Acute Surfing Injuries

Acute Injuries and Their Anatomic Distribution

Outpatient studies of surfing-related injuries have found lacerations to be the most common, accounting for 35–46 % of all injuries, followed by sprains and strains, contusions, fractures, and joint dislocations (Table 7.1). Those same studies found the head and lower extremities to be the most commonly injured regions of the body. Figure 7.2 shows the anatomic distribution of lacerations and fractures from a study of 1,237 self-reported surfing injuries. Hospital-based studies of injured surfers, which in all likelihood consist of higher-acuity patients, show a higher percentage of head injuries and factures, than do outpatient studies (see Table 7.2).

Table 7.1

Acute and chronic surfing-related injuries from outpatient studies

Study	Nathanson [10]	Taylor [8]	Nathanson [11]	Lowdon [9]	Lowdon [7]
Population	Prospective study of surfers in competition	Convenience sample interviewed at beaches in Victoria, Australia	Web-based survey of English-speaking surfers	Survey of International Competitors	Members of Australian Surfing Assoc., Victoria, AU
Average age (SD)	24 (7)	28 (7.9)	29 (10.6)	22 (3.7)	22 (5.7)
Male gender	87 %	90 %	90 %	89 %	95 %
Average #’s of years surfing	Unknown	12	11	11 (5 days per week)	8 (2.7 days per week)
# of acute injuries	116	168	1,237	167	311
Type of acute injury
Laceration/abrasion	35 %	46 %	42 %	45 %	44 %
Sprains/strains	39 %	29 %	12 %	37 %	29 %
Contusions	9 %	0	13 %	5 %	4 %
Fractures	5 %	9 %	8 %	10 %	16 %
Dislocations	4 %	11 %	2 %	2 %	1 %
Other^a	9 %	5 %	23 %	1 %	6 %
# Chronic/overuse injuries	Unknown	71	477	20	26

^aIncludes tympanic membrane rupture, tooth fracture/avulsion, concussion, hypothermia, and near drowning

Fig. 7.2

Distribution of 572 self-reported surfing-related fractures and lacerations (Photo: Adapted from Nathanson et al. [11])

Table 7.2

Hospital-based studies of surfing-related injuries

Study	Allen [13]	Chang [14]	Taniguchi [15]	Taylor [8]	Hay [16]	Hay [16]
Population	Hospitalized patients, Kaiser Hospital, Waikiki (includes 12 bodysurfers)	Hospitalized patients, Queens Medical Center (includes 21 bodysurfers)	Emergency Department, Kahului Community Hospital	Emergency Department, Victorian public hospitals	Discharged home, Royal Cornwall Hospital (includes bodyboarders)	Hospitalized, Royal Cornwall Hospital (includes bodyboarders)
Location	Waikiki, Oahu	Oahu	North Shore, Oahu	Victoria, Australia	Cornwall, England	Cornwall, England
Number of subjects	36	47	90	267	190	22
Average age	20	Approximately 27	Unknown	75 % <30 years old	27	27
Male gender	92 %	Unknown	Unknown	83 %	80 %	80 %
Injury type
Laceration	11 %	13 %^b	83 %	47 %	38 %	0
Sprain/ligament rupture	5 %	13 %	0	12 %	21 %	0
Fracture^a	30 %	45 %	7 %	14 %	14 %	64 %
Dislocation	5 %	2 %	3 %	2 %	13 %	10 %
Contusion	3 %	2 %	0	0	14 %	0
Drowning/near drowning	8 %	2 %	0	0	0	4 %
Solid organ injury intra-abdominal bleeding	17 %	2 %	0	0	0	4 %
Concussion/intracranial	3 %	17 %	0	3 %	0	18 %
Tympanic membrane perf.	8 %	0 %	4 %	0	2 %	0
Other	8 %	4 %	0	21 %^b	0	14 %^d
Body region
Head/face	39 %	34 %	49 %	42 %	42 %	18 %
Neck	17 %	21 %	0	3 %	7 %	18 %
Back	5 %	0 %	0	1 %	2 %	4 %
Thorax	0	4 %	12 %	6 %	4 %	0
Upper extremity	8 %	6 %		16 %	12 %	4 %
Lower extremity	6 %	19 %	31 %^c	23 %	18 %	32 %
Intra-abdominal/ Retroperitoneal	14 %	2 %	0	0	0	14 %
Other/unknown	11 %	17 %	0	9 %	3 %	10 %

^aIncludes two tooth fractures

^bIncludes total of four eye injuries

^cIncludes upper and lower extremity injuries

^dIncludes laryngeal fracture and uretheral rupture

Mechanisms of Injury

Understanding the common mechanisms resulting in surfing-related injuries is useful when caring for an injured surfer and is essential to the development of injury prevention strategies.

Surfboard

Nearly all studies exploring mechanism of injury have found that the majority of acute injuries are caused by collisions between surfer and surfboard (see Table 7.3). Most commonly, surfers are struck by their own boards, but they can also be struck by the boards of others, particularly in crowded surf breaks. Since the near-universal adoption of surfboard leashes, injuries from other surfers’ loose boards have become less common, while injuries from the surfer’s own board have become more common [7].

Table 7.3

Mechanism of surfing injuries

Study	Nathanson [10]	Taylor [8]	Nathanson [11]	Lowdon [9]	Lowdon [7]
Population	Prospective study of surfers in competition	Convenience sample interviewed at beaches in Victoria, Australia	Web-based survey of English-speaking surfers	Survey of International Competitors	Members of the Australian Surfing Assoc., Victoria, AU
Average age (SD)	24 (7)	28 (7.9)	29 (10.6)	22 (3.7)	22 (5.7)
Male gender	87 %	90 %	90 %	89 %	95 %
Average #’s of years surfing	Unknown	12	11	11 (5 days per week)	8 (2.7 days per week)
# of acute injuries	116	168	1,237	167	311
Cause of acute surfing injury
Surfboard	29 %	42 %	66 %	47 %	53 %
Seafloor	24 %	18 %	17 %	9 %	13 %
Wave force/“wiping out”	12 %	36 %	7 %	≥4 %	≥6 %
Body motion	16 %	0	5 %	16 %	17 %
Marine animal	2 %	1 %	3 %	0	1 %