Most of the data on injuries is from retrospective studies based on questionnaires or from medical records collected for other purposes. This makes it prone to different limitations (including recall bias or underestimation of minor injuries) and potentially leads to imprecise epidemiological evaluations [13]. Taking into account these considerations, the available data as a whole nevertheless allows us to draw a general risk profile of the sport (Table 21.1
).

According to the relevant literature, acute injuries range between 69 and 78 % of all windsurfing injuries [13, 21]. With respect to injury distribution, lower limbs are the part of the body most commonly affected (Table 21.2
). Most injuries are lacerations or puncture wounds due to contact with equipment and the sea floor and sprains or fractures due to the foot straps.

In the series by Nathanson and Reinert [13], out of 339 acute injuries, the foot was the most common site of acute injury (17.7 %; n = 65), followed by the knee (9.4 %; n = 32), and the ankle (8.6 %; n = 29). Foot injuries were mainly lacerations (48 %; n = 31), while more than half (57 %; n = 35) of knee and ankle injuries considered together were sprains. The upper limbs were the second most affected area of the body (18.5 %; n = 62) with ligamentous injuries and sprains (55 %; n = 34) and shoulder dislocations (15 %; n = 9). Head injuries mainly consisted of contusions (4.7 %; n = 16), while injuries to the trunk were mostly chest wall contusions and rib fractures (8.2 %; n = 28) and back strains or intervertebral disk injuries (4.7 %; n = 16).

A similar injury pattern was found in competitors and elite windsurfers. In a study on 49 professional World Cup windsurfers, Gosheger et al. [22] found ankle strains to be the most common injuries (22 %; n = 57). Knee injuries were also frequent (11.5 %; n = 30). In the study by Kristen et al. [20] examining the Windsurf Freestyle World Cup/Euro-Cup regattas on Lake Neusiedl in Austria between 1997 and 2007, the most common injuries were as follows: sprains and ligament tears to the ankle and foot (18 %; n = 34); acute back pain (17 %; n = 32); head contusions (12.8 %; n = 24); cuts to the feet (11 %; n = 21); and knee injuries (9 %; n = 17). In their study on elite women windsurfers participating in the 2008 PWA World Cup in Fuerteventura in the Canary Islands, Penichet-Tomás et al. [24] found that knees and legs were the most common regions to be affected by injuries in slalom and freestyle respectively. In the series by Dyson et al. [19], muscle/tendon strains accounted for 45 % of new injuries, and acute soft tissue injuries were equally distributed in the upper (n = 129) and lower body (n = 133). Especially in the upper body, most of the injuries affected the shoulder, the upper arm, and the elbow complex (41 %), while 60 % of lower body soft tissue injuries were most frequently related to the knee or the lower leg, the ankle and foot. Finally, in the same study, serious bruising, cuts and abrasions (mainly involving the head and face, the leg and foot regions) were more common especially among wave and slalom.

Although most injuries sustained during windsurfing are minor (sprains, muscle strains, bruises and cuts [12, 13, 18–20]), more serious injuries may occur when windsurfing is practiced in extreme wind and wave conditions or when simple safety rules and procedures are not followed [25]. Kalogeromitros et al. [25] monitored all serious windsurfing incidents in the Aegean Sea during 1999 and reported 22 windsurfing injuries requiring hospitalization at a tertiary level center. These included two cases of drowning, three concussions (one serious enough to require mechanical ventilatory support for 24 h), and a young windsurfer who suffered a C2 fracture resulting in tetraplegia associated with tracheal obstruction requiring emergency tracheotomy.

Collision with equipment when overpowered by wind and waves is the most common cause of trauma [18]. This is the cause in 65–75 % of all injuries [13, 15], the majority of which are caused by the boom, mast and board [13, 23]. In the series by Nathanson and Reinert [13], more than one third of lacerations to the lower limbs were caused by the surfer striking the fin of the board while attempting to waterstart with long narrow “blade” fins causing significantly more injuries (68.5 %; n = 13) than swept-back wave-type fins (31.5 %; n = 6).

According to Fehske et al. [12], 22.3 % of injury events had an external cause such as collisions with kitesurfers or other watercraft. These were not considered as common causes of injury in other studies [12, 13]. According to Nathanson and Reinert [13], the impact with water and contact with the seafloor and marine animals were other important causes of injuries accounting for 12.1 % of the total when taken together. Reports of shark attacks on windsurfers are extremely rare [26]. A greater danger in tropical waters is posed by flying fish which can cause cuts, while collisions with marine turtles can be avoided by paying attention to the fairway [20].

Most injury events occur after 2 h of exercise. This may be caused by fatigue interfering with the proper execution of maneuvers [19]. Broken equipment was reported as a cause of injury in just 3 % (n = 10) of cases (Peterson et al. [18]).

Drowning is uncommon, as is hypothermia; in extreme cases, the latter can be fatal, and every possible measure should be adopted to prevent its occurrence [13, 25, 26].

According to Nathanson and Reinert [13], uncontrolled falls represent the most common injury dynamic resulting in more than one third of injuries.

Low-speed falls mainly lead to lower limb injuries ascribed to the pattern of “foot strap injuries”(Fig. 21.3
), while high-speed falls may cause shoulder and head injuries consistent with the mechanism of “catapulting”[13]. The latter occurs when sailors are unable to detach the harness quickly enough causing them to be launched into the air and often land on the mast or the boom. Anterior shoulder dislocations are usually caused by the boardsailor hanging onto the boom while falling. Falls can also lead to head injuries ranging from minor results such as hearing problems and tinnitus to severe concussion with loss of consciousness [25]. In the study by Nathanson and Reinert [13], jumping was the maneuver that most often led to injuries (21 %; n = 71), while launching, jibing, and waterstarting caused 9.4, 7, and 5.9 % of injuries respectively (Fig. 21.4
)

Since even the most extreme athletes spend less than 5 % of their windsurfing time jumping, this maneuver contributes to a disproportionately high number of injuries. Jumping, looping, and catapult falls also tend to cause injuries requiring medical treatment [13]. In addition, jumps involving rotations of the board and the athlete on both horizontal and vertical planes such as forward and backward looping are the most dangerous maneuvers (Fig. 21.5) [18]. While the consequences of the collisions with kitesurfers or other watercraft are generally absent or minimal, given that windsurfers can reach speeds of 30–60 km/h, potential outcomes include major injuries such as blunt trauma from the board top, craniocerebral trauma and cuts from the fin [20]. Collisions are especially common in the most popular windsurfing spots near cities, often crowded with windsurfers, kiters, and sailors especially during weekends, and they are caused by lack of concentration, ignorance or disregard of the right of way, and high-risk maneuvers [20]. Meteorological conditions, particularly strong winds and large waves [14], may also lead to incidents (Fig. 21.6), especially when weather conditions are unexpected or underestimated [18, 19].

The category of injuries referred to as “foot strap injuries” [22] is specific to windsurfing [16, 28] and represents the vast majority (75 %) of lower limb fractures and ligament injuries [13] involving the ankle, knee or foot. They occur during unexpected falls or a bad landing after a jump and are caused by the disproportionate rotational forces exerted on the lower limbs by the long lever arm of the board when the foot is wedged in the foot strap. This is a mechanism whereby the body twists at the knee on the fixed foreleg possibly causing fractures of the femoral shaft [25], the head of the fibula (Fig. 21.7) and the tibial plateau, as well as knee injuries including dislocations, lesions of the capsule, and tears to the meniscus and collateral and cruciate ligaments [28]. Foot and ankle injuries may also occur when the foot inserted in the foot strap is acutely pronated due to a bad landing or a fall. These include Lisfranc injuries; unusual in other sports, but potentially frequent in windsurfing [36].

The term Lisfranc injury refers to a wide spectrum of injuries including lesions to the bases of the metatarsals, the four distal tarsal bones and the Lisfranc ligament. The tarsometatarsal joint complex (also referred to as the Lisfranc joint) is architecturally shaped like a “Roman arch” with the base of the second metatarsal acting as its keystone. It is located proximally with respect to the other metatarsal bases, tightly recessed between the first and third cuneiforms in a mortise configuration. The Lisfranc ligament is a strong oblique ligament arising from the plantar-lateral surface of the medial cuneiform to insert on to the plantar medial aspect of the second metatarsal. The traumatic mechanism of these injuries usually involves excessive plantar flexion and abduction of the forefoot often associated with concurrent rotational, compressive, and translative forces [29].

A high level of vigilance is required when evaluating windsurfers who suffer from injuries stemming from this dynamic since delayed diagnosis may lead to post-traumatic arthritis. On examination, anterior foot pain may be associated with ecchymosis or edema of variable entity. In Lisfranc ligament injuries, pain is elicited by moving the first and second metatarsals in opposite directions or by passive abduction and pronation of the forefoot while holding the hindfoot in a fixed position. Plain radiography should be completed with an anterior-posterior weightbearing view and may allow the physician to detect the following signs: misalignment of the medial border of the second metatarsal with the medial margin of the middle cuneiform; diastasis between the first cuneiform and the second metatarsal base; and a small bony fragment between the base of the first and second metatarsal (fleck sign). CT and MRI are more reliable. MRI in particular may show ligament edema as an increased signal on T2-weighted sequences in the case of a strain or ligament discontinuity in the case of a tear, or fractures of the metatarsal bases and tarsal bones, while bone marrow edema within the inferior aspect of the middle cuneiform should be considered a secondary sign of ligament injury. CT is more sensitive to bone injuries allowing a better visualization of these fractures and aiding preoperative planning [28, 31].

Although the best approach to Lisfranc injuries is still debated, stage I (according to Nunley and Vertullo [32], Fig. 21.8) can be non-surgically managed by a non-weightbearing cast for 6–10 weeks with the majority of patients returning to their pre-injury sport activities. With regard to stage II and III injuries, most authors agree that the best treatment strategy involves prompt surgical intervention with anatomic reduction and fixation [32–35]. Despite this, Mitani et al. [36] reported the case of a 40-year-old professional female windsurfer who sustained a Lisfranc injury with a diastasis of more than 3 mm that was treated conservatively. Undeterred by the recommendation for surgical treatment, she was adamant in her preference for non-surgical management. Given that she was close to the late stages of her professional career, a long rest and rehabilitation period required by a surgical approach would have hastened her retirement. The conservative approach was possible because her specialty was racing which is much less demanding compared to wave riding and freestyle in terms of forefoot stresses in the foot straps, A special cork insole mounted inside a marine boot was adopted to support the longitudinal and lateral arch of the foot during windsurfing even when in the strap.