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:
2 Pull Phase
Pectoralis Major and Minor
3 Extend and Follow Through Phase
Exercises Designed for improving Paddling
Repeated shoulder extension
Prone cable single arm/alternating pull and internal rotation
Prone double arm or single arm theraband lat pulldowns
Prone back extension/Cobra pose
Prone Ys, Ts
Paddling Video Analysis
Reduce Drag: Head still, reduce side to side sway
Fingertips Entry:Relaxed hand, elbow high as fingertips enter the water first, create larger area.
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 http://www.xswimfit.com/videos/
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:
Trunk flexion (rounded back)
Trunk extension (straightened or elongated spine)
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:
The thoracic spine allows us to keep our chest and head up as we paddle.
Rotation occurs through the spine when we reach and paddle each side, when performing manouevres such as re-entries, cutbacks and aerials.
We rapidly transition from trunk extension to trunk flexion during the pop up.
We side bend and rotate to look behind for waves at timing of our take off spot.
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”.
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
Exercises for Thoracic Mobility
Middle Back Flexion
On hands and knees in four point kneeling
Exhale deeply as you round back
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!
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 / Bursitis / Subacromial Pain
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)
As you can see there are a lot of potential diagnoses which 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 appropriate management and whether or not imaging would be necessary (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 with you could be experiencing Rotator cuff related pain. However it is important that appropriate screening of the cervical spine (neck) as 40% of patients with primary shoulder pain responded to repeated movements of the cervical spine. (Littlewood
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).
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.
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.
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 attempt to relocate as able and get an X-ray post relocation to rule out fracture.
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.
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.
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).
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.
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.
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”
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
Key Rehab Principle Number 3: Set meaningful goals for the short term and long term for you to have 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.