How to Improve Your Paddling

Surfer’s spend approximately 54% of their time in the water paddling, 28% of the time we are waiting for waves and only 8% of our time is riding waves. 1 Improving our paddling efficiency can make a dramatic improvement in performance and enjoyment of our sessions. The better we are at paddling  the more waves we can catch while surfing!

Today’s article will break down the anatomy of the shoulder and its surrounding muscles involved in paddling.

We will then discuss technique of paddling plus the top exercises you can do to improve your paddling.


Shoulder Movements of Paddling

Paddling is the most important part of surfing. The stronger paddler you are the more waves you can catch. Paddling efficiently can also reduce your risk of developing shoulder pain also known as surfer’s shoulder.

Paddling movements can be broken down into 4 phases:

1 Catch Phase

2 Pull Phase

3 Exit Phase

4 Recovery Phase


1 Catch  Phase

The catch phase is when the hand in entering into the water. As your hand enters the water it creates a surface area for which we are able to move through water and create the drive to propulse our surfboard forwards.

Your fingertips should enter the water first, with a high elbow and a relaxed hand (see paddling video analysis with Kelly Slater below for more detail as to why this is important).

At this stage the Rotator Cuff begins to fire to preset and control the movement of the ball (humerus) in the socket of your shoulder (glenoid fossa).


Muscles involved with Catch Phase:




Teres Minor



2 Pull Phase

Prime Movers

Pectoralis Major and Minor

Latissimus Dorsi

Lower Trapezius


Biceps Brachii


3 Extend and Follow Through Phase

Triceps Brachii

Posterior Deltoid




Exercises Designed for improving Paddling


  1. Repeated shoulder extension
  2. Prone cable single arm/alternating pull and internal rotation
  3. Prone double arm or single arm theraband lat pulldowns
  4. Prone back extension/Cobra pose
  5. Prone Ys, Ts
  6. Tricep extension


Paddling Video Analysis

Key Points:

  1. Reduce Drag:  Head still, reduce side to side sway
  2. Fingertips Entry:  Relaxed hand, elbow high as fingertips enter the water first, create larger area.
  3.  Improve alignment for powerful paddle stroke:  Slight Lateral Roll along axis, as hand sinks down, follow with slight bend in elbow as you paddle close to your rail and slightly under your board

If you enjoy the videos then check out more from Rob Case at Xswimfit

How to Save Your Middle Back and Paddle Easier

Middle Back Surf Exercises

How to Save your Middle Back and Paddle Easier

How to Improve Your Paddling When Surfing

 The middle back is the connection between our lower back, neck, ribs and shoulders so its quite an important area to keep healthy!

The thoracic spine or more commonly known as the middle back is an important area for surfers.

The following article will outline:

  • Anatomy and movement that occurs in the thoracic area
  • Why this area is important for paddling and surfing
  • What exercises you can do to keep your thoracic spine mobile and healthy to help you paddle easier

Anatomy and Movement of the Thoracic Spine

The thoracic spine consists of 12 vertebrae and their corresponding joint and rib articulations.

You can think of the 12 vertebrae as being like the links on a bike chain, connected and held together by strong ligaments, muscles and other soft tissue.

The vertebrae are therefore able to move and glide one by one on each other to co-ordinate global movement of the spine

The main movements in this area include:

  • Breathing (respiration)
  • Trunk rotation
  • Trunk flexion (rounded back)
  • Trunk extension (straightened or elongated spine)
  • Side bending

Movement is assisted by the forces generated by muscles. Movement can be coupled on both sides which leads to extension and closing down the joints or forward flexion and opening of the joints of the spine.

Movements can be coupled towards one side to create side bending or rotation through each segment of the spine.

In a co-ordinated effort the ribs will rotate up or down around an axis at the same time.

To help visualise this relationship of the movement between the thoracic spine and the ribs imagine the spine as the boat and the ribs as the oars of a rowing boat.

As we row forward the ribs are internally rotating upwards, round and in.

As we row backwards the ribs are externally rotating downwards, backwards and out.

To feel this try placing your arms out to your side at shoulder height.

Turn both your palms down to the ground to imitate the ribs rotating round and in.

Now turn both your palms up to imitate the ribs rotating downwards, backwards and out.

To understand how rotation works for the spine and ribs: While turning your head and body to the right, keep your right hand facing palm up and with your left hand turn your palm facing down.

Repeat the opposite to the left, as you rotate left keep your left palm facing up and turn your right palm facing down.

Now you have more insight into how the thoracic spine and rib cage work in harmony. Moving together in synchrony as we paddle, breathe and move.


The shoulderblades which sit on top of the rib cage move and glide to assist shoulder movements.


  • Upward rotate on the rib cage when we reach forward to paddle (think coming round the corner to the sides of the rib cage)
  • Downward rotate as we pull the water underneath our board to propel us forward.

Why is this area important for Surfers?

5 key reasons for why the thoracic area is important:

  1. The thoracic spine allows us to keep our chest and head up as we paddle.
  2. Rotation occurs through the spine when we reach and paddle each side, when performing manouevres such as re-entries, cutbacks and aerials.
  3. We rapidly transition from trunk extension to trunk flexion during the pop up.
  4. We side bend and rotate to look behind for waves at timing of our take off spot.
  5. Loss of mobilty can affect the neck and shoulders as we paddle and increase risk of repeated strain injuries.

You’ll likely see anyone from a beginner or a veteran at your local spot who has a hard time lifting their heads up.

When we have reduced mobility in our thoracic spine we start to hunch more over the board. As a result we begin to compensate by over extending through our neck to keep our eyes up. The hyperextension crams and closes down the space of the joints of the neck, thus creating increased stress on the neck joints.

The thoracic area also affects our shoulder position. When we lack mobility in our thoracic spine we start to round our shoulders. This closes down the space in the shoulder joint which results in less space and increased stress  of structures in the subacromial space, primarily the supraspinatus/infraspinatus tendon and the subacromial bursa. Thus we are at more risk of developing “Surfers Shoulder”.

Key Points

  • The Thoracic Spine (Middle Back) is involved in breathing, sidebending and trunk rotation for turns and balance, thoracic extension for keeping our chest up when we paddle and flexion which occurs during pop ups when we bring our feet through underneath us or when crouching down to fit in the tube.
  • The Thoracic Spine is in close connection with the shoulderblades thus plays an important role of shoulder movements
  • Reduced thoracic mobility can lead to compensation up into the neck where we over extend and put more stress on our neck joints
  • Reduced thoracic mobility puts more stress on our shoulder joints as we tend to round our shoulders we decrease the space available for structures in the subacromial space

Thoracic spine paddling


Exercises for Thoracic Mobility

Middle Back Flexion

On hands and knees in four point kneeling

Exhale deeply as you round back

Middle back extension mobility exercise

Middle Back Extension

Inhale through your nose as you extend your spine the other way and look straight ahead

Upper Middle Back Extension

Inhale through your nose as you extend your spine. Lift your head up off the ground.

Maintain length through your spine without overarching through your neck. 

Lower Back Extension

Inhale through your nose as you pushup from the floor.

Keep your hips and legs as relaxed as possible, allow for sagging of the lower back to the ground.


Lower Back Extension + Middle Back Rotation

Push your upper body up from the floor.

Look over your shoulder from side to side.


Lunge with Middle Back Rotation

Start in lunge position, foot placed both hands on the ground and your foot outside of your hands, lift one arm up towards ceiling as you inhale

How to Paddle Better

If you want learn more I advise checking out Rob Cases other videos they’re excellent! 

New Movie for John John Florence

Surf Movie JJF

About the movie

John John Florence has teamed up with Director Blake Keuny, who also directed the critically acclaimed “Done” in 2013 and Brain Farm Studios to produce this visually stunning movie “A View From A Blue Moon“. The film was released in Oahu, Hawaii November 11 and worldwide November 12, 2015. It is the first surf film to be shot entirely in high definition Red cameras and phantom 4K, providing the immersive sound and mesmerizing visuals. The cinematography in this trailer is nothing short of brillance and will definitely influence the way surfing is documented in the future.

The film follows Florence and his closest friends and fellow professional surfers to his favorite surfing destinations around the globe. From the South Pacific to the darkest uncharted waters of Africa, Florence faces a broad spectrum of emotions as he continues to seal his legacy as one of the most gifted surfers ever. And while the young Hawaiian is pulled in increasingly different directions, there is no form of pressure that will keep him from his ultimate goal — to redefine what is possible in the ocean.


About John John Florence

Born and raised on the North Shore of Oahu, Hawaii, 22-year-old John Florence learned to dominate powerful hawaiian surf and excel at the world famous Banzai Pipeline and Backdoor. Immensely talented, he developed a natural style at an early age at 13 years old he competed in the Vans Triple Crown and won the title 6 years later when he was only 19 years old. Over time John John has become known for his ability in the barrel and for becoming one of the best tuberiders in the world. He has taken skating influences and has been at the forefront of the progressive surfing movement performing awe-inspiring aerials, stylish cutbacks and frontside hacks impressing to both the surf community and the non surfer

2012 marked John’s first full year on the ASP tour, and he didn’t disappoint – placing 4th for the World Title, taking his first WCT win at the Billabong Rio Pro and winning Rookie of the Year.


Injury Prevention and Management of Pro Surfers

Wipeout injury pro surfers

With the rise of aerial surfing in free surfing and competitive heats; surfers like John John Florence, Filipe Toledo and Gabriel Medina who are elevating their air game to the highest heights are bravely putting themselves at a higher risk of ankle or knee injuries. John John Florence has already suffered from ankle injuries in 2014 and 2015 which have affected his ability to be among the world title race, although he has bounced back from both injuries strongly and surfed incredibly well on return. John John´s example is not only a testament to his resilence and talented atheltic ability but also the support of his family and medical staff who have assisted with his rehabilitation.


Injury prevention and exercise has become increasingly popular since Mick Fanning amazingly came back from an severe hamstring injury, which was surgically repaired in 2004 and went on to win the word title in 2007. Surfers more and more aware that keeping the body healthy and reducing injury risk are extremely important, especially for those who surfing is their primary job. An injury coud knock them out of contention for the Men or Womens´s WCT or WQS events and that serious implications on their chances of winning or requalifying.

Exercise, rehab and training can help to improve the stability of the ankle and knee joints and the reactive capacity of the tissues to respond to the stresses of rapid movements and forces from landing airs.

Of course, due to awkward movements and extreme forces injuries can still occur. There is always a risk that the unfortunate random events happen within recreational or professional sports. Thus, excellent rehab is essential for these athletes to get back to performing at their best; rehab is not only physically but mentally challenging too, fortifying and developing the traits of perserverance, motivation and desire to return to surfing in peak condition.


Notable surfers who have sustained injury in 2015:


Men´s Championship Tour

Jordy Smith (Knee meniscus injury at Western Australia, missed Fiji, Back injured at J-bay missed Tahiti, Trestles, USA, France, Portugal and Pipe, Hawaii)

John John Florence (High ankle sprain from landing an air in free surf, missed 2 events Fiji)



Michel Bourez (3 Fractures in fingers, Back Injured at Teahupo´ missed 2 events Rio Pro, Brazil and Fiji)  Bourez Injured at Teahupoó


Matt Banting (Knee Injured at Jbay on landing an air, Missed 6 events Fiji, Tahiti, USA, France, Portugal and Hawaii) Banting Injury Report


Brett Simpson (Back, injured at Huntington, USA missed 1 event Fiji)


Jeremy Flores (Face and cranium from falling onto reef missed J-Bay, South Africa)

Dusty Payne (Back injury, missed Portugal Pro)


Women´s Championship Tour

Stephanie Gilmore a left knee injury she suffered during a freesurf at the Margaret River, Western Australia. Missed 5 events (Brazil, Fiji, Huntington and Trestles, USA, Portugal)


Sally Fitzgibbons perforated ear drum at Fiji, surfed incredible that event with protective taping and padding



I really feel this is an excellent video on Courtney Conologue and her road to recovery.

Things to note is her outlet of her love for making art and spending time in gardens for her emotional and mental well being, and also long distance paddling on a surf ski for her physical and mental well being too.


Previous notable injury recoveries include: Owen Wright (Back), Dusty Payne (Ankle, Knee MCL and ACL), Courtney Conolgue (Ankle)

Learning About Shoulder Injuries

Surf Physio Shoulder Injuries

The following review will explore current understanding in relation to shoulder injury, assessment and treatment. Shoulder injuries were sustained in 16% of surfers followed for a 12 month period and in New Zealand shoulder injuries for surfers resulted in 1.2million dollars of treatment costs for ACC in the year 2015-2016

 Shoulder injuries are the third most common injuries to present to primary care (Mitchell et al., 2015). 

If you have experienced a trauma during a wipe out and as a result you have difficulty lifting your arm up due to pain or weakness. Then it is advisable to have an examination with your local physiotherapist or medical professional.


What injury could I have sustained?

Potential diagnoses and factors be examined:


  • Shoulder Strain

  • Shoulder dislocation

  • Rotator Cuff injury

  • Acromioclavicular (AC) joint injury

  • Sternoclavicular (SC) joint injury

  • Labral injury

  • Subacromial Pain

  • Fracture of the humerus, clavicle or scapula

  • Biceps strain, tear or tendinopathy

  • Pectoralis major strain

  • Referral from structures in the neck and the nerves that supply the shoulder and arm



  • Medical red flags: Cancer, Vascular, Lung and Heart Disease

  • Frozen shoulder/Stiff Shoulder/Adhesive Capsulitis / Neurological Guarding (severe loss of passive range of motion, 35-60 years)

  • Glenohumeral joint arthritis (least likely, >65 years, slow onset, severe loss of rotation range of motion)

Psycho-social Factors: 

  • Work, leisure, family, relationships, life experience, beliefs and fears

  • History of Anxiety or Depression

As you can see there are a lot of potential diagnoses that is why it is best to have a physical examination by a physiotherapist, or medical professional in your area. They will be able to discuss with you whether imaging ultrasound or MRI is also appropriate (MRI can only be requested by an orthopaedic surgeon in New Zealand).

If you are older than 40 years old, have no recent history of trauma and have developed a slow onset of pain in the shoulder you could have issues with your rotator cuff (4 muscles of the shoulder that help to control the movement of the humeral head in the socket).

However, it is important to note that 50% of patients over the age of 60 although they had rotator cuff tears on imaging they also had no pain. (Hashimoto, Nobuhara, & Hamada, 2003). So a rotator cuff tear on imaging does not necessarily mean that it is the primary source of your pain. You may experience mild to moderate weakness and have difficulty with day to day tasks such as reaching into a cupboard, sleeping on that shoulder or getting dressed. People who also have diabetes or vascular issues also have a greater risk of rotator cuff related pain.

There is also some evidence that an inflamed sub-acromial bursa (SAB) could be the primary pain generator in rotator cuff disorders (Blaine et al., 2005). See below for further elaboration in the section “What is Subacromial Pain?

Shoulder Dislocations

Shoulder dislocations are a risk for all surfers, solid conditions and big wave chargers have a bigger risk due to the greater forces of the wave and the height fallen during wipe outs.

If you know your shoulder has popped out of its socket and its your first time, the sooner it is relocated back into the joint the better.

If after a few failed attempts then seek a doctor, emergency department or somebody who is trained in how to safely relocate.

Risks with relocation include fractures to the humeral head “the ball” (Hil-sachs lesions) or glenoid and labrum “the socket” (Bankart lesions). Doctors will likely take an X-Ray post relocation to check that no further trauma was sustained.

If you are somewhere nowhere close to a hospital or medical attention, then the following methods are advised at your own discretion.

FARES technique

Requires 1 person

Start: the person is lying on the back in this position

Take the person’s affected arm at the wrist, extend the the elbow so it is fully straight by the persons side, Gently traction the arm by pulling at the wrist until resistance is met.

With the elbow straight, rhythmically move the wrist up and down multiple times starting with the arm out to the side at 45°, build up to 90° add rotation of the wrist so that the wrist faces upwards to the head, thumb pointing towards the wall and finish at 120 degrees.

Once relocated, place the persons hand on their belly, have them sit up. Place arm in a sling for the length specified by the doctor.


Spaso Technique

Requires 1 person

Start: The patient is lying on their back in this position.

The helper gently grabs at the persons wrist and brings the affected arm up to 90° so that the hand is pointing up to the ceiling. Next laterally rotate the arm (turning the thumb out towards you)

Alternatively, place your other hand on the chest and over the collarbone (clavicle) and firmly counter traction. (Not recommended if clavicle # has been sustained

Spaso technique
Spaso Technique

Matsen counter-traction technique

Requires two people

Start: Wrap towel around affected side of trunk to apply counter traction

Other person holds the arm flexed at 90° and then applies slight traction and rotate externally or internally to relocate the head of the humerus.


Self-relocation Technique

Start: Sit on a hard surface (e.g. table, floor).

Clasp your hands together, and wrap your forearms and wrists around your knee, which is bent at 90 degrees, (you may need some assistance to keep the hands together – a separate person can do this, or the wrists can be gently tied together with a t-shirt, towel, rope, crepe bandage whatever you have available).

From the upright sitting position start to lean backward with your head looking up to the sky, roof. In this position, you can gently increase the traction on the dislocated shoulder.

Now push your shoulders forwards like you are hunching over your chest. This movement increases the chance to generate to spontaneous reduction.

More information on shoulder dislocations can be found at

What is Subacromial Pain?

Subacromial Pain is the most commonly diagnosed shoulder disorder, accounting for nearly half of all shoulder injuries. However, it is an umbrella term which covers a wide spectrum of injuries including: Rotator cuff tendonipathy, rotator cuff tears, subacromial bursitis. 

The name subacromial refers to structures that are under the acromion bone of the shoulderblade, as you will see in the diagram below: this includes the rotator cuff muscles and cuff tendons and sub acromial bursa (a fluid filled sac that is between the tendon and the bone and thus helps to prevent friction allowing for sliding and gliding of the tendons with movement), these structures become irritated or sensitised and nerves send danger signals up to your brain which produces pain as an output to protect you.

Shoulder anatomy

What does the rotator cuff do?

The rotator cuff (RC) is a group of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) responsible for stabilisation of the shoulder during active movement. The rotator cuff tendons are not isolated structures as they work together. It was also discovered by looking at the anatomy in cadavers that the tendons of supraspinatus, and infraspinatus  join to form a common insertion onto the humerus (Clark & Harryman, 1992). Thus, if there is significant trauma to the tendon it can affect multiple muscles in the shoulder.


Keep in mind with a Clinical Examination..

The usefulness of pain provocation examination tests to accurately enable the clinician to arrive at a structurally specific diagnosis has been challenged (Lewis, 2009). Since the rotator cuff tendons are not isolated structures, it is extremely unlikely that an individual test can isolate a specific tendon during physical examination. Furthermore, due to the close relationship between the sub-acromial bursa and the tendons during movements and this can also reduce reliability of the test results. 

Some tests are more accurate than others

  • A positive painful arc test result (pain on lifting the arm up between 60°-120°and reduces after 120°) is sensitive to sub acromial pain, but does not tell you what specific structure 
  • A positive external rotation resistance test result is sensitive for detecting issues with the rotator cuff.
  • A positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear (Hermans et al., 2013).
  • A loss of passive range of motion can indicate stiffness in the shoulder resulting from Adhesive capsulitis or Arthritis.


MRI shoulder sub acromial



An X-ray is used to rule in or out a Fracture, Infection or suspected Malignancy. It is recommended post traumatic injury.

An ultrasound (US) scan allows assessment of the rotator cuff and is cost-effective relative to a magnetic resonance imaging (MRI) scan. However, it does depend on the ability of the operator usually a  radiographer.

A MRI scan can also be used to evaluate tear size and retraction of the tendon, but in addition the rotator cuff muscles can be assessed for muscle wasting and fat deposits which allows a better prediction of surgical outcomes after RC tendon repair.

Imaging can give information to your Doctor and Physiotherapist, however may people have findings on their scans that are considered normal age related changes, discuss further with your health practitioner. 

Management and Rehab is an excellent option as..

Conservative management of partial thickness rotator cuff tears is highly recommended prior to surgical treatment (Ainsworth & Lewis, 2007; Pegreffi et al., 2011). There is considerable evidence for the effectiveness of rehab exercises to improve outcomes in patients with rotator cuff disorders (Kuhn, 2009). It is superior to no treatment or placebo treatment in primary care (Lombardi, Magri, Fleury, Da Silva & Natour, 2008). A recent multi-centre randomised control trial has shown that nearly 75% of patients improved clinically and avoided surgical repair by performing rotator cuff strengthening, soft tissue mobilisation and joint mobilisation despite having full thickness tears (Kuhn et al., 2013).

A three phase rehabilitation programme has been recommended in the management of rotator cuff tears (Pegreffi, 2011) – see table below.

Phase One
1. To relieve pain, adjust activites
2. To restore normal range of motion – active and passive

Phase Two
1. To improve functional strength of the rotator cuff muscles
2. To restore the ability of the rotator cuff to dynamically stabilise the humeral head during active movements

Phase Three
1. Task-specific rehabilitation exercises
2. Facilitate integration of the kinetic chain

There are low recovery rates for degenerative rotator cuff tears, even three years after onset with considerable effect on health and basic activities of daily living (Winters, 1999). Degenerative rotator cuff tears tend to occur in older patients (over 50 years old) and commonly present with progressive shoulder pain with no obvious history of trauma (Clement, Nie & McBirnie, 2012). Four factors have been identified with successful outcome following conservative management (Tanaka et al., 2010). They are:

  • Preserved active range of motion in external rotation ( more than 52°)
  • Negative impingement signs
  • Little or no atrophy of the supraspinatus muscle
  • Preserved intramuscular tendon of the supraspinatus tendon

There was no additional benefits with inclusion of manual therapy with exercises from the findings of a systematic review (Ho, Sole, & Munn, 2009). There was only minor effect on pain intensity after 5 weeks.


Subacromial injection
Subacromial injection


If you do consider having a cortisone injections you shoulde be aware of the pros and cons before having one.  


Steroid injections give a short term pain relief (~3-6months).

In shoulders that don’t settle within 6-12 weeks of conservative management then a cortisone injection can be useful to reduce irritability and allow for exercises to be performed with decreased pain.


However the potential harmful effects such as reduction in tendon size and decreased tissue quality, and risk of future tear or rupture is greater (Pegreffi, Paladini, Campi, & Porcellini, 2011).


Should I have surgery?

This is ultimately your choice, its best to discuss your options with your doctor and orthopaedic surgeon.

My professional opinion is to always rehab your shoulder to the best of your ability first and use shoulder surgery as a last option.

There is good evidence to support an exercise program for 12 weeks of shoulder strengthening and mobility reduced pain and improved function equal to that of surgical outcomes.


  • Active 20 to 50 year old patients with an acute traumatic tear and severe functional deficit from a specific event are best treated with early surgery (Clement et al., 2012).
  • Patients who did not respond well to conservative management might benefit from surgical review. (Oh, Wolf, Hall, Levy, & Marx, 2007).


  • Complete restoration of muscle strength after surgery can take more than one year postoperatively to rehab.
  • This can mean considerable time off work, surf, life commitments!
  • Due to prolonged inactivity post surgery, the muscles decrease in size and strength which puts the tendon at risk of failure in the early stages of rehab
  • There is a risk of infection with surgery and other complications.


Factors associated with a better recovery post surgery

They include:

  • Greater pre-operative range of motion of the shoulder
  • Pre-existing rotator cuff integrity (size of tear, less retraction, less fatty tissue infiltration, number of tendons torn)
  • No previous surgery to shoulder i.e. biceps repair, AC joint
  • Healthy diet and nutrition
  • Absence of diabetes, obesity and other medical conditions that affect healing
  • Previous high level of sporting activity, good fitness


Shoulders are important to keep healthy for surfers, we need them for our paddle strength to get into waves and to generate the force in the pop up. Shoulder injuries are common and its best to get a physiotherapist, doctor or orthopaedic surgeon to take a look if shoulder especially if it is affecting your day to day tasks and limiting your surfing.

The good news is that there is strong evidence to support conservative management to improve strength and function for rotator cuff tears to get you back in the water and at your best.


ACC Statistics. Active claims for shoulder injuries and surfing for the year 2015-2016  

Ainsworth, R. & Lewis, J.S. (2007). Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine, 41(4), 200–210.

Blaine, T. A., Kim, Y.S., Voloshin, I., Chen, D., Murakami, K., Chang, S., et al. (2005). The molecular pathophysiology of subacromial bursitis in rotator cuff disease. Journal of Shoulder and Elbow Surgery, 14(1), 84–89.

Clark, J. & Harryman, D. (1992). Tendons, ligaments and capsule of the rotator cuff. Gross and microscopic anatomy. The Journal of Bone & Joint Surgery, 74(5), 713–725.

Clement, N. D., Nie, Y. X. & McBirnie, J. M. (2012). Management of degenerative rotator cuff tears: a review and treatment strategy. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology, 4(1), 48.

Hashimoto, T., Nobuhara, K. & Hamada, T. (2003). Pathologic evidence of degeneration as a primary cause of rotator cuff tear. Clinical Orthopaedics and Related Research, 415, 111–120.

Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L. & Bierma-Zeinstra, S. M. (2013). Does this patient with shoulder pain have rotator cuff disease?: The rational clinical examination systematic review. The Journal of the American Medical Association, 310(8), 837–847.

Ho, C., Sole, G. & Munn, J. (2009). The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review. Manual Therapy, 14(5), 463–474.

Fermont et al., (2014). Prognostic Factors for successful recovery after arthroscopic rotator cuff repair: A Systematic Review. JOSPT, 44(3), 153- 162.

Kuhn, J. E. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery,18(1), 138–60.

Kuhn, J. E., Dunn, W. R., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., et al. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder and Elbow Surgery, 22(10), 1371–1379.

Lewis, J.S. (2009). Rotator cuff tendinopathy. British Journal of Sports Medicine, 43(4), 236–241.

Lombardi, I., Magri, A. G., Fleury, A. M., Da Silva, A. C. & Natour, J. (2008). Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial. Arthritis and Rheumatism, 59(5), 615–622.

Mathew, B. (2014). Rotator cuff disease. Retrieved from

Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: diagnosis and management in primary care. BMJ : British Medical Journal, 331(7525), 1124–1128

Oh, L. S., Wolf, B. R., Hall, M. P., Levy, B. A. & Marx, R. G. (2007). Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research, 455, 52–63.

Pegreffi, F., Paladini, P., Campi, F. & Porcellini, G. (2011). Conservative management of rotator cuff tear. Sports Medicine and Arthroscopy Review, 19(4), 348–353.

Sher, J., Uribe, J., Posada, A., Murphy, B. & Zlatkin, M. (1995). Abnormal findings on magnetic resonance images of asymptomatic shoulders. The Journal of Bone & Joint Surgery, 77(1), 10–15.

Tanaka, M., Itoi, E., Sato, K., Hamada, J., Hitachi, S., & Tabata, S. (2010). Factors related to successful outcome of conservative treatment for rotator cuff tears. Upsala Journal of Medical Sciences, 115(3), 193–200.

Winters, J. (1999). The long-term course of shoulder complaints: a prospective study in general practice. Rheumatology, 38(2), 160–163.

Yamaguchi, K., Ditsios, K., Middleton, W. D., Hildebolt, C. F., Galatz, L. M., & Teefey, S. A. (2006). The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. The Journal of Bone and Joint Surgery. American Volume, 88(8), 1699–704.

3 Keys to Rehab Success

3 Key Principles to Rehab Success

The bridge to success
The bridge to rehab success!


This article will discuss 3 important concepts when it comes to success in your rehab: Progressive loading, pacing your rehab and meaningful goal setting.

1. Progressive loading for improved tissue tolerance

This is a simple but very important concept to grasp. Tissues in your body respond to stress i.e. bones respond to load and strengthen the periosteum (outer layer of bone), muscles grow in size under weights training due to increased load. Tissues that have been injured can only handle reduce loads to begin with, but it is very important to progressively load the tissue to help it regain its ability to tolerate higher loads

However the key is like most things in life is moderation.. not over doing it … or undoing it, its like finding the sweetspot on your surfboard too far forward and you nosedive, too far back and you’ve got to paddle harder against the increased resistance.

Below is a diagram that shows how nomal tissue responds to load, how injured tissue responds to load (reduced ability to tolerate load) and tissue after rehab (increased ability ro tolerate load).

Light blue (1) is under load, tissues not receiving enough load. Medium blue (2) more load stimulates maintenance of tissue and The Dark Blue (3) is the “sweet spot”of optimal loading for tissue development. Pink way too much! (4-5).[pullquote align=center]

Key Rehab Principle Number 1: Loading optimally will help stimulate tissue healing, but too much or too little is detrimental to your success.


Optimal loading

Light blue (1) is under load, tissues not receiving enough load. Medium blue (2) more load stimulates maintenance of tissue and The Dark Blue (3) is the “sweet spot”of optimal loading for tissue development. Pink way too much! (4-5).

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Key Rehab Principle Number 1: Loading optimally will help stimulate tissue healing, but too much or too little is detrimental to your success.


2. No pain = No gain, right? Incorrect, pacing yourself is better

Although I love to to see people with determination and grit, people that push themselves too hard without the ability of the tissues to tolerate load are destined to have flare ups.

Pain and determination
Pain and determination

So if its feeling great, don’t go too hard to soon. Start at 30-50% of what you used to do for training and build back up. I.e. if you run for keeping fit and normally you would run for 30-45mins duration then as an example start out with a low intensity 10min jog, slowly build up to 15mins by the end of the week if tolerated, or try jog-walk-jog choose a distance you feel comfortable with say jog for 3 lampposts walk for 2, then jog again for 3. If its upper body you do 20 pushups normally, start with as many as you can tolerate say 3 sets x 5 reps and progress from there.

If an exercise is making your pain worse stop it, either modify your technique or position or scrap it and swap it to another exercise that puts less stress on the tissue. (Discuss with a local physiotherapist, personal trainer in your area who can guide you to an exercise more suitable)

Also take notice of how you feel later that day, that night and the next day. Obviously there will be some post exercise discomfort in the muscles and you can also have pain to begin with as the tissues get used to the loading. So if you are sore from pushing too hard too soon, then do a really light session with unweighted or low load movements to help with active recovery.

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Key Rehab Principle Number 2: Learn to pace yourself by starting at reduced effort and build back up.



3. What do you want to achieve with your rehab?

Purpose. Direction. Achievement. Success. Reward.

Goals can sometimes be tricky to set, people often tell me “I want to get better and have no pain” and obviously “I want to get back in the water and surf again” is another important one. The reality is a goal has to be meaningful to you, it has to be what you want to achieve what will drive you to succeed, it may be “I want to be able to run around with my kids in the backyard” or it may be” I want to charge bigger waves” or “noseride 2 foot peelers”

MEANINGful Goals
MEANINGful Goals


If you like you can be more specific with timeframes but this is up to you

I.e if its a knee injury it might look something like this:

I want to be able to hop 30 times on my injured leg and have no pain in 2 weeks

I want to be able to walk 15 minutes with no pain in 2 weeks

I want to be able to pop up to my feet in one movement in 1 month

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Key Rehab Principle Number 3: Set meaningful goals for the short term and long term for you to have success


Claim Success

The end of the bridge is success! 2 guys dropped in on this guy, he doesn’t give up instead he pushes them off and ends the wave still standing with this awesome claim.


Surf Physio Pain Advice

Pain 😦

Pain it @#/% hurts!

Pain is a complex human phenomena that bloody hurts! By why do we experience pain? Below I will discuss some of the key important concepts when it comes to understanding your pain.

Pain is a way of communicating danger.  Within our tissues there are sensors that detect sensory stimulus (i.e. sharp or blunt pressure, heat, smell, sound etc.). These messages are then sent to the brain via our immune and nervous systems. Then the brain has to rapidly process these inputs and decide if there is a iminent threat or danger that is worth paying attention to!

A simplified version is to see that pain is like an alarm system that which when under stress can become highly sensitive to external and internal threats in order to protect yourself from harm.

Therefore, pain is an important a protection mechanism that’s essential to your survival. Without it we would regularly put ourselves in danger.

Note that pain does not equal damage. Often times people who have had injuries have variable pain responses and everybody is unique and responds differently; they may have a hardnosed approach “i’ll be right mate” and keeping pushing through the pain or they may be more fearful of doing more damage and so stop working and start to avoid doing tasks that they think might “cause” more pain i.e bending down to pick something off the floor, heavy lifting, walking.

So now check out this excellent video below for a more visual representation of explaining pain


Video: Understanding pain

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Self reflecting on your pain

To understand more about your pain ask yourself the following questions and write down your answers on a piece of paper or wherever you feel comfortable to do so


Your history

When did the pain first start?

What were you doing at the time?

What happened next, what happened later that day?

How long before you saw a medical professional or physiotherapist?

What thoughts did you have about the pain ?

How did you react? Were you scared?

How does the pain make you feel?

How much does the pain affect your ability to work, do tasks at home, surf?

Was there any other significant event going on in your life at the time?


Past Medical History

Have you injured this area before? If so when was the last time?

Have you had any scans/medical imaging?

Have you had any previous therapy for this injury? What worked well? what didnt you find useful?

What other injuries have you sustained during your life?

Have you had any fractures / broken bones?

Family history of Arthritis? Diabetes? Cancer? Heart Disease?

Have you recently lost a lot of weight in a short period of time?

Any severe night pain?

What medication are you currently taking?


Your behavior of symptoms

Where do you feel your pain?

Do feel pain in any other parts of your body?

Have you injured this area before?

How would you describe what your pain feels like?

Do you get any strange feelings like pins and needles, numbness or weakness? If yes, where and how long does it last for?

What does it feel like when you first wake up and get out of bed?

During the rest of the morning what does it feel like? And how does it feel into the afternoon and at night?

What activities, positions or tasks make your pain worse?

How long into when you’re walking/running does it start?

When aggravated how long does it last for before easing away? (Seconds/minutes)

What makes it feel better?

Is there ever a time where you feel no pain?

How many hours of sleep are you currently getting? What are your normal hours of sleep?

Are you late nighter/early riser?

What makes you sleep better/worse?


What is your outlook on pain

Do you think it is getting better, staying the same or worsening?

What do you think you can do to get better?

What do you want to achieve the most in the short term? Long term?

From this you might start to see even how other factors going in your life i.e. workload, relationships or even the death of a close relative lead to increased emotional stresses which greatly impact on your pain

Next up I will discuss what you can do to help yourself get better and improve your self management of your pain

Remember if in any doubt go see a medical professional or physiotherapist and get it checked out!