Common, mostly minor, and most surfers seen in hospital go homeEmerging evidence
Across 17 studies, 31% to 35% of recreational surfers and 42% to 49% of competitors had an injury of any kind in a year; in Australia the rate was 1.79 major injuries per 1,000 hours, and a narrative review puts it at "0.74-1.79 injuries per 1000 hours of surfing". Most are cuts and bruises from the board. In UK club surfers, "65% of the surfers never required professional medical treatment"; in Cornwall's main hospital, 90% of surfing injuries "were minor/moderate (allowing for discharge after treatment)"; and a US emergency department study concluded that "Surfing injuries are common but rarely serious", with 95.7% of surfers treated and sent home.
Among upper limb surfing injuries in US emergency departments, nearly half of them at the shoulder, "Only 2.2% of injuries required hospital admission". NHS inform says new shoulder pain "should begin to settle within 6 weeks". The pooled surfing figures come from surveys and hospital records of mixed quality, so treat them as rough guides (low certainty).
Sources 1, 2, 3, 4, 5, 6, 7, 8, 9
Paddling is most of surfing, and it loads the rotator cuffEmerging evidence
Paddling takes about half of every session: 51% of the time in 42 world-class heats, "the greatest amount of time spent during surfing was paddling (54 ± 6.3% of the total time)" in 12 nationally ranked surfers, 44% in heats at 3 professional events, and 47.0% of recreational surfers' sessions, against 2.5% to 8% riding waves. A 2-hour training session and a Portuguese championship showed similar shares.
A review says "Muscles that are active during paddling are mainly internal rotators and muscles that are involved in shoulder flexion": the muscles that turn the arm inwards and lift it forwards. The broad back muscle (latissimus dorsi) worked hardest as paddling sped up, and in a lab study of adults who weren't surfers, the trapezius worked most as the arm came back out of the water.
Sources 10, 11, 12, 13, 14, 15, 16, 17, 18
The shoulder is one of the commonest places surfers get soreEmerging evidence
Across 20 studies of gradual-onset surfing injuries, "Spine/back (29.3%), shoulder (22.9%), and head/face/neck (17.5%) were the most frequently reported locations of musculoskeletal injury, whilst the most common mechanism of injury was paddling (37.1%)". In 1,473 New Zealand surfers, "Prolonged paddling was the most commonly reported mechanism of injury (40% of all injuries)", and the shoulder led with 146 gradual-onset injuries, 64% of them long-lasting. Across 10 studies of shoulder injuries, paddling was the commonest cause (about 58%), and about two-thirds built up over time rather than coming on suddenly; these pooled figures are low certainty. In Australian surfers, the shoulder was 16.4% of sudden major injuries.
"In surfers with shoulder complaints, external rotation range of motion and external rotation strength are impaired", and the review's authors write that "The surfer’s shoulder is characterised by external rotation deficit, as opposed to internal rotation deficit in the thrower’s shoulder, and it differs substantially from shoulder complaints in swimmers". In 13 competitive surfers, "Internal rotation strength was greater than external rotation strength bilaterally". These are surveys and small lab studies: they show where surfers hurt and how paddling works, not that paddling alone causes the pain.
Sources 19, 20, 21, 22, 2, 16, 23
Who gets it, and what the shoulder blade doesEmerging evidence
Gradual-onset injuries went with "board type, higher ability, older age, more hours/year, and years of surfing", and were 13% more common in longboarders than shortboarders, an association the survey couldn't explain. Shoulders were hurt suddenly by 4.3% of recreational and 7.4% of competitive surfers in a year. Older recreational surfers paddled for the same share of a session as younger ones.
Recreational surfers' shoulder blades moved no differently from non-surfers': "Surfers and non-surfers both presented with 48% positive scapular dyskinesis tests". A shoulder blade that moves a little unusually is common in people without pain, so it isn't the whole story.
Sources 20, 24, 25, 26
Popping upEmerging evidence
The pop-up starts as a fast push-up through both hands, with peak hand force about body weight; it lasted 1.20 seconds, "60% push-up and 40% reaching/landing phase". No study links the pop-up to shoulder pain; in our reading it loads the front of the shoulder like a push-up.
Source 27
Wipeouts and dislocations: a small share of injuries, but they matterEmerging evidence
Taking a fall with the arm out and turned outwards can dislocate the shoulder, and in 4 bodysurfers, waves forced arms overhead into the sand. In Cornwall, "Anterior shoulder dislocations accounted for 10% (n = 19) of injuries not requiring hospital admission"; on Australia's Gold Coast, "Dislocation rate was 4.9%, with shoulder dislocation (76.5%), and patella dislocation (12.1%) being the most common types", which by our own calculation makes shoulder dislocations about 3.7% of surfing hospital visits.
In professional surfers seen at one orthopaedic centre, "in shoulder, 48% had instability, 42% had a rotator cuff tear, and 35% had a superior anterior-posterior labral tear"; among surfers sent for a scan, the shoulder was the commonest joint injured, and "Only 17% (n = 11) of acute surfing injuries required surgery". These are selected groups, and they overstate how serious most surfers' shoulder pain is.
Sources 28, 29, 6, 30, 31, 32
The neck and upper back from paddling with your head upEmerging evidence
"Paddling also exposes the surfer to prolonged periods in cervical hyperextension, which may explain why head, neck, and face injuries made up the third largest percentage of all chronic or gradual-onset injuries reported", the review's authors explain (cervical hyperextension means the neck bent backwards). The neck was the third commonest gradual-onset injury in New Zealand (105 injuries, 46% long-lasting), and paddling holds the trunk arched, with the back muscles and middle trapezius working. Surf medicine clinicians link poor upper back (thoracic) mobility with neck, low back and shoulder problems, as an expert opinion.
Serious neck injuries are different: "Spinal injuries most commonly occur when the surfer's head strikes the seafloor", and at Australian beaches "Surfers were more likely to be injured through shallow water diving than swimmers (27.6% vs 2.2%)".
Sources 19, 20, 33, 28, 34, 35
Surfer's myelopathy: rare, but the warning sign to knowEmerging evidence
In 19 novice surfers in Hawaii, "all patients complained of sudden onset of low back pain while surfing, followed by bilateral leg numbness and paralysis progressing over 10-60 minutes", and "Admission severity appears to be most predictive of neurologic outcome". "Sixty-four cases of surfer's myelopathy have been reported to date" (in 2016), the first case series having named it in 9 people after surfing lessons. Across 104 cases of the same injury from arching the back, 58% followed surfing, and "The most frequent clinical feature was bladder or bowel dysfunction (84%)".
"The most common suggested mechanism of injury is static hyperextension" (lying with the back arched), and awareness "may lead to avoidance of the predisposing postures". It is rare, mostly in first-time surfers, and the warning signs say what to do.
Sources 36, 37, 38, 39, 40
When a scan or test mattersEmerging evidence
Most surfers' shoulder pain needs no scan to start treatment: the NHS advises seeing a GP or physiotherapist if shoulder pain hasn't improved after 2 weeks, and shoulder blade "dyskinesis" is as common in non-surfers. An X-ray is needed for a shoulder that may be dislocated or broken: the NHS says "You will usually have an X-ray to check your shoulder is dislocated". An ultrasound or magnetic resonance imaging (MRI) scan matters for sudden weakness after a wipeout (a possible rotator cuff tear), a shoulder that keeps slipping, or deep catching that doesn't settle with rehab, and an urgent MRI for surfer's myelopathy.
Sources 41, 26, 42, 36
How it usually goesEmerging evidence
Most overload settles: NHS inform expects new shoulder pain to start settling within 6 weeks, and the NHS says shoulder impingement "usually gets better in a few weeks or months". But surfers' shoulder problems can linger: 64% of gradual-onset shoulder injuries in New Zealand surfers lasted 3 months or more, and "the shoulder represented the largest proportion of chronic injuries (>3 months) (44.4%)" among sudden injuries, which is a reason to start the plan early rather than paddle through it. After a dislocation, the NHS says "It usually takes 6 to 12 weeks to recover from a dislocated shoulder. It may take up to 16 weeks to fully return to playing some sports". No one can promise a date.
Sources 9, 43, 20, 24, 42
When it isn't surfing: the causes the warning signs cover
Some shoulder pain has causes surfing didn't create, and the warning signs follow the pages behind them. Shoulder or arm pain with chest pain that feels tight or spreads to the arms, neck or jaw can be a heart attack, and pain that comes on with effort and eases with rest can be angina: the NHS heart attack and angina pages give the 999 and NHS 111 signs. The NHS shoulder pain and dislocated shoulder pages say when a shoulder needs A&E or same-day help.
After hitting the seabed, the UK's concussion guidelines for grassroots sport treat severe neck pain as a red flag and say someone with a suspected neck injury should be moved only by trained professionals; NHS inform's neck injury page and the NHS whiplash page say which symptoms need help the same day. Sudden low back pain with symptoms in both legs or bladder changes is a 999 call, as the NHS back pain page says, and surfer's myelopathy is described in case series of novice surfers.
Rarely, shoulder pain is a sign of something else, and the hub's lines follow the NHS pages: weakness in one arm with a drooping face or slurred speech on the stroke page; shoulder tip pain in pregnancy on the ectopic pregnancy page; a sudden headache, jaw pain or problems with sight on the polymyalgia rheumatica page, with the vision loss page's 999 call for suddenly losing sight; and chest or shoulder pain with a cough that won't go away on the lung cancer page. A hot, swollen joint can be septic arthritis, which the NHS page says needs checking quickly. An arm that suddenly turns cold, pale and painful may have lost its blood supply (acute limb ischaemia), and a national confidential enquiry's (NCEPOD) leaflet says "Seek emergency medical help immediately". A throbbing, swollen, red, warm arm can be a clot, which the NHS thoracic outlet syndrome page says needs an urgent GP appointment or NHS 111; the NHS DVT and pulmonary embolism pages describe clots and a clot that reaches the lungs; and the NHS fainting page says to call 999 for someone who fainted while exercising.
The neck lines follow the NHS cervical spondylosis and neck pain pages and NHS inform's neck problems page, which says to contact your GP practice urgently for clumsiness in your hands or arm symptoms that are getting worse. NICE's spinal injury guideline lists diving among the dangerous ways to hurt the neck, and a Wigan hospital leaflet says new nerve symptoms from the neck are likely to settle fully within 6 to 12 weeks. The diving line gives the Royal Life Saving Society UK's rule (water at least 1.5 m deep with 7.6 m clear ahead, from a standing start) and the Royal Society for the Prevention of Accidents' warning that water depths change with the tide.
The rotator cuff lines follow UK care pathways from the British Elbow and Shoulder Society and the British Orthopaedic Association, which say a tear caused by an injury needs urgent referral, with a primary care review. The 12-week and 3-month lines follow a cohort of 452 people with tears that didn't follow an injury, about 75% of whom did well with physiotherapy over 2 years, and a trial in which specific exercise reduced the need for surgery at a year. The shoulder blade nerve line comes from studies of top volleyball players, in whom wasting of the muscle over the back of the shoulder blade was usually painless and most kept playing.
Sources 44, 61, 41, 42, 62, 45, 63, 46, 36, 80, 81, 82, 83, 84, 65, 95, 79, 68, 67, 66, 73, 74, 75, 64, 78, 90, 91, 69, 70, 71, 72, 85, 86, 87, 88, 89
