Extreme Sports Series: Understanding The Demands of Surfing (Part 2)

 In Prolonging Health


So on this blog I will continue to expand on the demands of surfing. In part one I focused on its most popular version, shortboard riding. Part 2 will also shed some light into other popular forms of surfing and some general injury management advice for surfers.

Differences in board equipment

Surfboards can vary in size. By default we call longboards those above 2.5m in length. These are easy to paddle and very stable boards which are relatively easy to stand up on. However, all this stability comes at the cost of decreased maneuverability.

Stand-up Paddling board or SUPs are thicker and wider than longboards. Some will have up to 5m in length and are designed for flat waters and speed. Other will be shorter and adapted for wave riding. A paddle is used to propel the board forwards and assist in directing the board as needed.

Tow-in boards are similar to surf skis, heavier, narrow and about 2m in length with foot straps attached to it. Apart from being less likely to become airborne, that allows the surfer to navigate through more turbulent waters at higher speeds with good control. Tow-in is a modality reserved for big wave riding when a surfer cannot generate enough speed to catch the wave by paddling into it.

Finally, bodyboards are used to ride waves in a prone position and with the assistance of short swimming fins. Apart from helping the surfer to catch a wave, the fins in conjunction with the board’s rail are used to assist in steering the board given that bodyboard are fin-less. Different from other boards, these are made of foamy material. Despite been easier to ride and popular among inexperienced surfers and children, professional bodyboarders are known to charge at waves most surfers tend to avoid.

Injuries and Management Overview

Unfortunately, spinal trauma in surfing is well documented. Particularly bodyboarding and bodysurfing where the surfers rides head first. Similar to those who dive head first in a swimming pool, the impact of onto the sea bottom can be disastrous leading to injuries ranging from minor cervical spine sprain to spinal cord injury, quadriplegia and even death.

One study set out to investigate the profile of those who suffered wave-related spinal cord injuries in Hawaii. The typical victim was a male tourist of large build in his 40s, with little previous experience in wave-riding activities. Anyone that presents floating or complaining of neck pain after a wipeout should be treated as possible spinal injury until proven otherwise.

Another scenario is drowning due to the leash being tangled up at rocks and reefs on the sea bottom. Leashes or leg ropes can also strangle limbs and fingers, leading to fractures and dislocation. The force of the wave imposed on the surfboard can be unforgiving.

The energy of a breaking wave is significant. It estimated a 1-m-wide slice of a 3-m-high wave has the equivalent of 73 hp and its power increases as a square of its height. Interestingly, traumatic injuries caused solely by the hydraulic forces of a wave (i.e., not involving surfboard or sea floor) are uncommon, even in very large surf.

Interestingly, traumatic injuries caused solely by the hydraulic forces of a wave are uncommon, even in very large surf. #performbetter @pogophysio Click To Tweet

Long bone fractures, shoulder dislocations, and other significant injuries have been attributed to getting hit by big waves, but such injuries are unusual. Greater danger in large surf is the risk of being held-down underwater by a breaking wave turbulence. Though underwater hold-downs almost never exceed 30s, when a surfer is already puffed out it can be quite challenging. Many tow-in surfers wear flotation vests to improve buoyancy in the highly aerated water that is formed after large waves break.

A two-wave hold-down is every big surfer biggest fear. However, the number of big-wave surfers that have drowned over the last three decades is in the single digits, and  there is no literature report of any drownings while tow-in surfing, despite the fact that tow-in teams have been chasing the largest rideable swells on the planet for over 15 years.

Wave-Riding Injuries

Acute muscle and joint injuries acquired while riding waves are on the rise among today’s top surfers. About 19 % of all acute injuries were found to be knee sprains and strains. As mentioned in the last blog, aerial maneuvers pose a great risk Landing it safely requires skill and a stable base which is can be only provided by good foot and body positioning whilst airborne. It is now common to see professional surfers sidelined by ankle sprains and fractures as well as ACL rupture and injuries to the meniscus from poor landing. When wave riding, the knee of the back leg is in a flexed valgus position, placing high loads on the medial collateral ligament during forceful maneuvers.

Poor technique, lack of flexibility, insufficient warm up can contribute strains of the hamstrings, neck, and back while executing snaps and lay-backs.

Poor technique, lack of flexibility, insufficient warm up can contribute strains of the hamstrings, neck, and back while executing snaps and lay-backs. #performbetter @pogophysio Click To Tweet

Overuse Injuries

According to one studies using time-motion analysis, 50 % of a surfer’s time is spent paddling and 45 % is spent remaining still, while only 3–5 % is spent actually riding waves, so it comes as little surprise that most overuse injuries stem from paddling. Sustained paddling is required to get out to the takeoff zone and maintain one’s position in the presence of currents, while short bursts of paddling at maximum effort are needed to successfully catch waves, dodge unfavourable waves, and avoid oncoming surfers. An internet based survey pointed to 18% being shoulder related, 16% backs and 9% necks.

A combination of mobility, strength and good technique is paramount in avoiding overuse injuries due to paddling.

Neck and Back

The overall description of the ideal paddling posture requires lumbar and thoracic spine extension to raise the upper chest off the deck of the board and allow for an ergonomic paddling stroke. The neck is also kept in slight extension

Excessively tight hip flexors, for instance, can jeopardize the ideal pelvis positioning and increase the shearing forces over the lumbar spine. Beginners and those surfing after prolonged periods of inactivity often complain of burning muscular pain in the upper trapezius and rhomboid muscles due to overuse. In turn, muscle endurance is also needed to sustain the long paddling sessions. Neck soreness can be exacerbated by the tendency of some surfers to hyperextend the neck to compensate for inadequate back extension due to fatigue or lack of lumbar and thoracic flexibility.

Although back and neck sprains as well as muscle spasms can be resolved spontaneously over time with rest from aggravating activities, it is paramount to address contributing factors and get a clear diagnosis in order to prevent recurrence and chronicity. The demands of all surfing modalities require the avid surfer to be vigilant with compensatory patterns and loading though their bodies. Failing to do it so can lead to further injury such as disc injuries, nerve entrapments and spondylolysis.

Good core strength is needed for an efficient paddling endurance. A study from Gillam et al. demonstrated that while surfers had more powerful shoulder flexion and extension than other athletes, they had significantly weaker abdominal strength.

Good core strength is needed for an efficient paddling endurance. #performbetter @pogophysio Click To Tweet

A one-legged standing extension test reproduces the pain caused by spondylolysis, and a bone scan alongside CT scan and MRI can be obtained to confirm the diagnosis. Stress fractures of the pars interarticularis generally heal with conservative therapy but often require 4–6 months of cessation from sports, though some may require spinal fusion later in life.

Upper Extremity

Surfing is an overhead sport and some estimate a surfer may take as many as 2,000 paddling strokes in a 2-h session. Shoulder strains and impingement syndromes of the supraspinatus tendon caused by paddling are very common, and intermittent shoulder pain has been found to affect nearly 30 % of amateur surfers. Surfers with scapular instability, muscle imbalance, or poor paddling biomechanics are particularly predisposed to shoulder problems. Those who fail to raise their chests off the deck of their board while paddling require more shoulder flexion during the recovery phase of the paddling stroke, causing an overload of the surrounding structures.

Stand-up paddlers have to extra careful with their shoulders too. Having the right equipment is crucial. An extra long paddle will put the shoulder into repetitive strain under an impingement position. On the other hand, a short paddle may lead to excessive bending forward and increase loads and shearing via lumbar spine.

Muscle imbalances between and anterior shoulder chain  and scapula stabilisers have also been highlighted as a cause for shoulder pathology in surfers. This muscular imbalance leads to scapular protraction and movement of the humeral head high into the shoulder socket resulting in compression of the rotator cuff tendons and subacromial bursa. Years of surfing can lead to fraying of the supraspinatus tendon as it courses under the acromion which can progress to a torn rotator cuff.

Tow-in surfers must be extra cautious on take off. Like wakeboarders and waterskiers, a great deal of force in put onto shoulders at the start of the tow movement, before the board starts to glide over the water as the speed picks up.

In general, return to surfing after shoulder rehabilitation should only occur upon restoration of a painless full range of motion, at first surfing on a relatively buoyant, easy gliding board to reduce the paddling burden.

Shoulder rehabilitation should last a minimum of 6–12 weeks and may take up to a year. The repetitive stresses of paddling, duck diving, and popping up may delay full recovery or lead to further injury if allowed to soon.

Injury Prevention

Basic Safety Recommendations

  • All surfers should be strong swimmers who can swim 1 km in less than 20 min and are comfortable swimming alone in the ocean.
  • Each surf break is unique and has different characteristics depending on wave height, tide, and wind. When surfing in a new local, surfers should familiarize themselves with safe entry and exit points, currents, and underwater hazards. This is best done by talking to local surfers and observing the surf break for a minimum of 10 min prior to entering the water.
  • Surfing is a skill sport that takes many, many years to master. Surfers should respect their own limits and gradually work their way up the ladder in terms of wave size and difficulty.
  • Surfing to exhaustion, particularly in large surf, is a mistake. Wise surfers pace themselves so that at any given moment they are able to hold their breath for at least 20 s in preparation for an unexpected hold-down. Fatigued surfers should paddle to shore or rest outside of the takeoff zone.
  • Breath-hold training may induce syncope and should only be practised on land in a safe, supervised environment.


Collisions with surfboards are the leading source of surfing injuries with 60–70 % of those injuries inflicted by the board’s sharp fins, nose, or tail. Minor modifications in surfboard design, described below, are unlikely to significantly alter performance characteristics and would likely go a long way toward reducing injury rates.

  • Beginners should use boards made entirely of shock-absorbing closed-cell foam and equipped with flexible rubber fins. These boards provide an extra measure of safety for neophytes who have minimal board control or familiarity with the surf and are at high risk of being struck by their own boards. These boards also reduce the risk of injuring near by surfers.

Bruno Rebello (APAM)

Bruno Rebello

Featured in the Top 50 Physical Therapy Blog


Mei-Dan, O., & Carmont, M. R. (2013). Adventure and Extreme Sports Injuries Epidemiology, Treatment, Rehabilitation and Prevention. London: Springer London.

Schram, B. L., Hing, W. A., Climstein, M., & Furness, J. W. (2017). A Performance Analysis of a Stand-Up Paddle Board Marathon Race. Journal of Strength and Conditioning Research, 31(6), 1552-1556. doi:10.1519/jsc.0000000000001707

Yanagawa, Y., Omori, K., Kondo, A., Oode, Y., Itoi, A., & Sakuraba, K. (2015). Analysis of patients with bodyboarding injuries transported by physician-staffed emergency helicopter. Journal of Emergencies, Trauma, and Shock, 8(1), 39. doi:10.4103/0974-2700.145416

Schram, B., Hing, W., & Climstein, M. (2015). Profiling the sport of stand-up paddle boarding. Journal of Sports Sciences, 34(10), 937-944. doi:10.1080/02640414.2015.1079331

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