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)
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.
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:
Rotator Cuff injury
Acromioclavicular (AC) joint injury
Sternoclavicular (SC) joint injury
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)
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 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.
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.
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
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.
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.
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.
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.
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. Goals 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.
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
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 https://thesportsphysio.wordpress.com/2014/05/24/rotator-cuff-disease-a-guest-blog-by-benoy-mathew/
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.
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
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
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!