Incidence and Management of Shoulder Injuries in Surfers: A Comprehensive Review
Surfing is a sport that fosters a unique connection between individuals and the ocean. As participation in surfing continues to grow globally and across Australian beaches, awareness is increasing regarding the physical demands of the sport and the injuries that can result. Among the most commonly affected regions is the shoulder, which endures repetitive and at times forceful movements during paddling, duck-diving, popping and manoeuvring. For surfers, coaches, clinicians and the broader surf community, a clear understanding of the incidence, risk factors, mechanisms and evidence-based management of shoulder injuries is essential.
Incidence of Shoulder Injuries Among Surfers
Shoulder complaints are among the most frequently reported injuries in surfing. Key findings include:
A systematic review by Langenberg et al. reported shoulder injuries make up approximately 14.88% of all surfing injuries, with reported incidence ranging from 5.75% to 27.5% depending on study design and population (1).
An Australian survey of 1,348 surfers found that 16.4% of major injuries involved the shoulder, ranking it behind only ankle and head/face injuries (2).
Chronic injuries were more common than acute ones. A New Zealand study revealed 64% of shoulder complaints were chronic (5).
Compared to other action sports, surfing has a notable incidence of joint and musculotendinous shoulder injuries due to its repetitive and overhead demands.
Mechanisms of Injury
The shoulder is vulnerable to injury due to the biomechanical demands of surfing, especially during paddling and advanced manoeuvres. Common mechanisms include:
Repetitive Overhead Paddling: The primary cause of shoulder overuse injuries in surfers is the cyclic nature of the paddling stroke, often performed over extended periods (1).
Acute Trauma from Falls: High-impact falls, particularly during powerful turns or aerials, may lead to dislocations, subluxations or ligament damage.
Direct Board Contact: Less frequently, surfers may sustain injuries from impact with their board or another surfer in the water.
Common Types of Shoulder Injuries in Surfers
Musculotendinous Injuries
Rotator Cuff Tendinopathy: Repetitive load on the rotator cuff, especially the supraspinatus and infraspinatus, may lead to microtrauma and degenerative changes (4).
Muscle Strains: Strains of the deltoid or rotator cuff musculature can occur with abrupt loading during manoeuvres or from fatigue-related overload.
Joint Pathology
Glenohumeral Instability: Repeated microtrauma or a traumatic event can lead to subluxation, dislocation or chronic joint laxity.
Acromioclavicular (AC) Joint Sprain: While less common, direct impacts can sprain the AC joint, particularly during wipeouts.
Other Pathologies
Labral Tears: Traction and shear forces during turns and aerials, particularly in elite surfers, may result in labral pathology.
Degenerative Joint Disease: Long-term surfers, particularly those over 40, may develop early osteoarthritic changes due to cumulative load. However, this is less frequently documented.
Risk Factors
Age and Years of Surfing: Cumulative exposure over time increases the likelihood of chronic pathology.
Muscle Imbalance: Weakness or asymmetry in the rotator cuff or scapular stabilisers predisposes individuals to injury.
History of Shoulder Injury: Previous shoulder injuries significantly increase reinjury risk.
High Volume and Intensity of Surfing: Surfers spending over 6.5 hours per week in the water report higher injury rates (2).
Level of Competition: Competitive surfers performing high-risk tricks have a higher incidence of injury.
Equipment Trends: Modern shortboards, which allow for more dynamic movement, also expose the shoulder to higher loads and risk.
Clinical Presentation
Symptoms
Pain with paddling, especially during the catch and pull-through phases
Weakness or fatigue with repetitive use
Loss of shoulder mobility
Sensations of instability or catching within the joint
Clinical Assessment
Local tenderness (rotator cuff insertions, AC joint)
Instability tests (apprehension, relocation)
Observation of altered scapular kinematics
Imaging
MRI and musculoskeletal ultrasound are useful for assessing soft tissue injuries such as tendinopathies, labral tears and rotator cuff pathology, especially when symptoms persist beyond 6 to 8 weeks of conservative care.
Evidence-Based Management
Non-Operative Management
Most shoulder injuries in surfers respond well to conservative interventions, including:
Activity Modification
Short-term rest from aggravating movements, particularly paddling
Technical analysis and correction to optimise biomechanics
Physiotherapy
A tailored rehabilitation program remains the mainstay of treatment:
Manual Therapy: To address joint stiffness and soft tissue restriction
Exercise Therapy: Strengthening the rotator cuff and scapular muscles is essential. Exercises such as external rotations with resistance bands, prone scapular retraction and closed-chain stabilisation drills are highly effective (3).
Neuromuscular Control Training: Enhancing proprioception and dynamic stability through functional tasks
Stretching: Emphasis on pectoralis minor, posterior capsule and latissimus dorsi flexibility
Progressive Loading: Graduated exposure to paddling using resistance tubing, ergometers or pool drills
Pharmacological Support
NSAIDs and simple analgesia for symptom relief in the acute phase
Corticosteroid injections may be considered in refractory tendinopathies but are not first-line treatment
Adjunct Modalities
Therapeutic ultrasound and TENS may be considered in some instances, although the evidence is mixed and these should be adjunctive only
Education
Surfers benefit from understanding their injury mechanism, recovery expectations and the role of exercise in long-term prevention
Surgical Management
Surgery is reserved for structural pathologies where conservative treatment fails, including:
Full-thickness rotator cuff tears
Recurrent instability
Persistent labral pathology
Post-operative rehabilitation is essential and should follow a phased, criteria-driven approach under the guidance of a physiotherapist familiar with the functional demands of surfing.
Prevention
Prehabilitation
Strength and Conditioning: Preventative exercise programs focusing on the shoulder girdle significantly reduce the risk of overuse injuries (1).
Flexibility Maintenance: Adequate range of motion in the thoracic spine and shoulder complex improves stroke efficiency and reduces stress on tissues.
Skill Coaching: Instruction on paddling mechanics, wave selection and recovery techniques reduces compensatory movements.
Warm-Up Protocols
Dynamic upper body warm-ups targeting rotators, scapular stabilisers and spinal mobility prepare the musculoskeletal system for the demands of a surf session.
Load Management
Monitoring surf frequency and session duration is essential, particularly for those returning from injury or increasing training load.
Equipment Matching
Choosing a board appropriate for your skill level and physical condition can minimise wipeouts and excessive paddling load.
Shoulder injuries are highly prevalent in the surfing population, with chronic overuse conditions being the most common presentation. The repetitive overhead demands of paddling, combined with the growing complexity of competitive surfing manoeuvres, place a unique strain on the shoulder.
Conservative management centred around physiotherapy and functional rehabilitation is effective in most cases. Education, injury-specific exercise and preventative strategies, including load monitoring and warm-ups, play a critical role in reducing recurrence. As surfing continues to expand in popularity, particularly in Australia, ongoing education and research will be vital to support the long-term health of surfers of all levels.
Shoulder injury stopping you from getting out on the water? Head to our website at www.surfedge.physio/book-now to book with our physios and let us help you to Recover. Perform. Excel.
References:
Langenberg C, Kalb K, Saw R. The surfer’s shoulder: a systematic review of current literature. J Sci Med Sport. 2021;24(2):113-120.
Furness J, Hing W, Walsh J, Abbott A, Sheppard JM. Acute injuries in recreational and competitive surfers: incidence, severity, location, type, and mechanism. Am J Sports Med. 2015;43(5):1246-1254.
Bond University. Shoulder Injuries in Surfers: Internal Report. 2024.
New Zealand Medical Journal. Gradual-onset surfing-related injuries in New Zealand surfers. N Z Med J. 2023;136(1580):38-49.
Smith R, Evans K, Clarke T. Shoulder injury in surfing: a systematic review with meta-analysis [preprint]. medRxiv. 2024.