The sport of surfing began many centuries ago in the South Pacific region. It was an integral part of Hawaiian culture, practiced by both commoners and royalty. Its practice declined during the 1800s when it was discouraged by missionaries to the islands, until a revival began in the early 20th century. Surfing is now enjoyed as a recreational sport by over 18 million people of all ages worldwide . In addition, surfing competitions exist on the primary and secondary school, college, and professional levels. With the advent of newer technological means of creating rideable waves in pools and indoor arenas, surfing has expanded from coastal and great lake communities to inland areas and even cruise ships.
Surfing is an intermittent sport with paddling accounting for 50% of the activity, limited motion/waiting for suitable waves 40%, and 5% to 10% spent actually riding the wave. Surfers possess a high level of aerobic fitness and peak VO2 values are comparable to other upper body endurance-based athletes. There are cyclical bouts of low intensity activity soliciting aerobic metabolism intermixed with high-intensity exercise utilizing both aerobic and anaerobic metabolism [2••]. As a highly active water sport, those participating in surfing are prone to a unique constellation of acute and chronic conditions of which physicians caring for these patients should be aware. This article reviews some of the more frequent illnesses and injuries seen in these athletes and discusses relevant preventive strategies.
Surfboard riders are prone to a multitude of acute and chronic conditions (Table 1). Several authors have presented retrospective studies on the frequency and type of injuries incurred by surfers. Lowdon et al.  published one of the first studies on the prevalence of injuries among 346 Australian surfers that required either medical attention or days lost from surfing. They reported that lacerations were most frequent, representing 41% of all injuries. Most lacerations were to the head, mainly to the skull, with lower extremity lacerations next most frequent. The second most common injury type was dislocations, sprains, and strains, which represented 35% of all injuries. Other injuries included skull and body fractures, contusions, and tympanic membrane perforations. Overall, 3.5 injuries per 1000 surfing days were reported in their study.
In 2002 Nathanson et al.  published a larger study of 1348 surfboard riders. They also found lacerations to be the most common injury, but with head and neck lacerations to be equally as prevalent as those to the lower extremity. Contusions, sprains and fractures were also seen. The majority of contusions affected the trunk and lower extremity. Sprains were most reported in the lower extremity, with knee injuries most often seen. The majority of fractures reported by Nathanson et al.  were to the head and neck. Of note, both Lowden et al.  and Nathanson et al.  found a higher level of injury severity in more advanced surfers, who often engage larger waves in more extreme conditions.
The large majority of injuries reported in both studies were from contact with a surfboard, usually the rider's own board. The rail and fins of the board accounted for most of the injuries seen. The sea floor is another common source for injury, responsible for 17% of injuries in the study by Nathanson et al. . Surfing over coral reefs versus sand is a significant risk for sea floor injuries. Additional risks involved with surfing include injury leading to either drowning or hypothermia should the surfer not be able to safely return to shore. Lacerations have the added potential of becoming infected with sea-borne organisms, and should be treated for Vibrio and Pseudomonas species, along with the more common Staphylococcus and Streptococcus species.
Preventive safety measures can help reduce the frequency and severity of injury. Surfing helmets are available and their widespread use could help reduce the number of head lacerations and fractures [4••]. But Nathanson et al.  reported that only 8% of surfers in their survey used helmets. Rubber guards on the board's nose and soft-edged or rubber-guarded fins would also help reduce the number of lacerations, and are thought not to alter surfboard dynamics to any appreciable degree. Their use is limited, as reported by Nathanson et al. , with 40% of surfers reporting using nose guards and only 5% of surfers having soft-edged fins. Protective eyewear specifically designed for surfing is available from several manufacturers, and may afford both protection from ultraviolet rays and orbital trauma.
The use of a board leash in preventing injury is controversial. Leashes do seem to have reduced the number of accidents involving loose boards hitting other surfers. Leashes also provide the downed surfer with access to a floatation device in the event of serious injury. But by keeping the board in close proximity to the surfer, leashes may increase the risk of board-induced injury. In addition, board recoil from the leash is another mechanism for injury to the surfer. Two articles of surfboard-related ocular trauma implicate the board nose as the common mechanism of injury, with Kim et al.  implicating leash recoil as one causative factor . Leashes are sold in varying lengths. Longer leashes may decrease recoil injury, with the consequence of increased risk of injury to others.
A recent addition to potential injury associated with surfing has been coined surfer's myelopathy [7••]. Nine cases were reported occurring between 1998 and 2003 in Hawaii. It seems to affect first-time surfers or those learning the sport. It appears to be a nontraumatic paraparesis/paraplegia that may be associated with hyperextension of the lower thoracic and upper lumbar segments in an untrained surfer. No injury was noted during surfing, but most patients complained of mild mid to low back pain, lower extremity weakness, and urinary retention. MRI evaluation displayed signal change in the lower thoracic spinal cord. Although most patients achieved significant improvement or resolution, complete paraplegia has been noted. The pathophysiology is possibly due to a secondary ischemic event from hyperextension and spinal cord traction, resulting in spinal cord injury and the abnormal signal findings of the lower thoracic/upper lumbar segments of the spinal cord seen on MRI. Although not enough is known of this disorder to make definitive recommendations on prevention, swimming and surfboard paddling for endurance and strength gains as well as flexibility training may reduce the incidence of this malady, particularly because it does not appear to affect experienced surfers.
Surfers, like most other athletes, are not immune to overuse injuries. The overhead nature of paddling is similar to swimming. Shoulder impingement syndrome, acromioclavicular arthrosis, and rotator cuff strains are common to surfers. Treatment is similar to that seen in other sports and includes activity modification, rotator cuff and periscapular strengthening, injections, and arthroscopic surgery for refractory cases or complete cuff tears. Prevention is geared toward a strengthening and consistent paddling regimen to maintain adequate strength and fitness [2••].
Neck and lower back pain are common complaints of surfers. Degenerative disc and joint disease account for a fair amount of these complaints, particularly among ageing surfers. Surfing has been implicated in a number of cases of spondylolysis and spondylolisthesis due to its repetitive hyperextension of the lumbar spine [2••].
Spine trauma in the cervical spine is of particular concern because of the potential for central cord syndrome. Over 50% of these injuries occur in older surfers, particularly those with pre-existing spondylosis [9••]. The mechanism of injury was similar with nearly all of the injuries caused by hitting the ocean floor (75%) resulting in neck hyperextension [9••]. Injuries usually occur in the lower cervical spine and can result in burst fractures and complete spinal cord injuries.
Interactions with other sea life is an inevitable part of ocean sports. Marine animals caused 3% of reported injuries in the study by Nathanson et al. . The more frequently encountered life forms that cause harm to surfers are the free-floating coelenterates, stingrays, and coral reefs. Although clinical presentation may vary, certain general treatment principles apply to any type of marine envenomation.
First, most marine envenomations become infected . Common organisms include Staphylococcus, Streptococcus and Vibrio species. Special culture media is needed for growing marine organisms, and the laboratory should be alerted if there are concerns for these. Broad-spectrum empiric coverage is warranted, and either third-generation cephalosporins or fluoroquinolones are good choices to treat Vibrio species. Lacerations should be allowed to heal secondarily, or if necessary, by delayed primary closure. Second, retained foreign bodies should be considered in most envenomations. Depending on the mechanism of injury and level of clinical suspicion, investigation of a retained foreign body can be done through wound exploration or appropriate radiographs. Tetanus prophylaxis should be given if the patient's immunity is not up-to-date.
Coelenterates are invertebrate animals that are either free-floating or sessile. Surfers are more apt to encounter free-floating coelenterates such as the true jellyfish, box jellyfish, and Portuguese man-o-war. These animals have a main body and multiple dangling tentacles with numerous venom-filled cells called nematocysts. Nematocysts inject their toxins subcutaneously in response to either chemical or mechanical stimuli. Local symptoms of nematocyst envenomation include burning pain, erythema, edema, urticaria, and bullae formation, all which may lead to skin necrosis (Fig. 1). Systemic effects of the toxin can damage respiratory, cardiovascular, gastrointestinal, renal, musculoskeletal, neurologic, and ocular organs.
Initial treatment involves preventing further toxin release by removing any remaining tentacles or other animal parts. Larger animal parts can be carefully removed with forceps or gloves. No consensus exists as to the best method of inactivating nematocysts and reducing pain. Various treatments recommended by published and anecdotal sources include cold packs, heat application, or irrigation with a multitude of liquids. Study results are conflicting due to the variety of study designs and jellyfish species used; their results are summarized in Table 2. Fresh water or vigorous rubbing is not recommended because these may induce further nematocyst discharge .
Further treatment of pain and dermatitis includes either oral or parenteral analgesics and antihistamines. Systemic symptoms can appear many hours after exposure and duration of monitoring is usually based on severity of clinical presentation. Antivenin for the box jellyfish is available, and should be used if envenomation from this animal is known or suspected. Additionally, clear return precautions and parameters are warranted after discharge from medical care. Prevention strategies include avoiding areas where high numbers of nematocysts have been reported. Wetsuits may thwart some envenomations by preventing the toxin from reaching the skin, although stings through a wetsuit have been reported.
An interesting type of envenomation occurs with exposure to the larvae form of certain types of coelenterates. Known as seabather's eruption, this intensely pruritic rash is thought to represent a hypersensitivity reaction to the larval toxin. It has been reported most often on the eastern coast of the United States, the Caribbean, and as far north as Bermuda . It is thought that as the larvae get trapped in the swimwear, nematocysts discharge toxin. Further toxin release has been reported to occur when the bather then tries to rinse in fresh water .
Seabather's eruption presents as a urticarial maculopapular rash found in the areas of the body covered by the bathing suit. The rash can appear while the patient is in the water, or up to 1.5 days later. The rash can last anywhere from 2 to 28 days, with most reactions resolving in 1 or 2 weeks . Systemic symptoms may include fever, nausea, vomiting, and headache, and occur most often in children . Initial treatment can involve the topical application of substances listed in Table 2. Further treatment is symptomatic and may include topical corticosteroids, oral antihistamines, and oral steroids for severe cases. Burnett  reports that oral thiabendazole has also been efficacious. The bathing suit should be thoroughly cleaned as larvae can persist and re-envenomate at a later time.
Stingrays are commonly found in coastal waters of the United States. They are bottom-dwelling creatures that are usually encountered while surfers are entering or exiting the water in shallow, sandy areas. Their sting is provided by a sharp ensheathed spine located in their tail. This spine can penetrate wetsuits and booties. These stings usually involve the lower extremity and present with pain out of proportion to the wound appearance . Wounds can be either punctures or lacerations. Pieces of the sheath or spine may be present. Recommended initial treatment is hot water immersion to inactive the heat-labile toxin. Retained animal product should then be excluded by either wound exploration or radiographic examination. Prevention consists of avoiding areas and times of day with known higher concentrations of stingrays. Also recommended is shuffling one's feet while walking through the shallow sand. This alerts stingrays as to human presence, whereby they scatter and do not get stepped on directly. Additionally, having larger numbers of surfers or bathers around also discourages stingrays from congregating, thus decreasing possible exposure.
Coral reefs are a common source of surfing-related lacerations. Because of the variety of plant and animal species found on these reefs, coral envenomation usually consists of toxin from multiple sources. These include sea urchins and sea cucumbers. Coral lacerations usually present with pain, pruritis, and erythema (Fig. 2). The area should be irrigated and debrided if necessary. Acetic acid has been recommended for stinging pain associated with coral envenomation . These wounds tend to heal slowly and may need antibiotic therapy such as fluoroquinolones to completely heal.
Auditory exostoses are bony outgrowths that arise from the temporal bone and protrude into the ear canal. Although not definitively proven, it is generally accepted that exostoses form as a response to chronic cold water exposure. Water less than 65°F (18.5°C) is reportedly needed for exostoses to form . Kroon et al.  have demonstrated that cold water surfers are at higher risk for developing exostoses. Auditory exostoses are usually asymptomatic, but can present with conductive hearing loss, frequent ear infections, and occasionally pain. They are usually found bilaterally and multiple exostoses can usually be seen in a single ear canal.
The presence and severity of auditory exostoses has been shown to be directly correlative with the amount of time spent in the water. In 1996 Deleyiannis et al.  published a study of 21 surfers in Oregon. They reported a higher prevalence of exostoses in surfers with more years of participation and in those who surfed more times a year. Wong et al.  reported data from 307 professional surfers. They found that as the number of years surfed increased, the prevalence and degree of severity of exostoses also increased. Along with their cold water data, Kroon et al.  also validated the results of Wong et al. .
The consistent use of ear plugs may help prevent exostoses from forming. Even with the high prevalence of exostoses, only 17% of surfers in the study by Nathanson et al.  reported earplug use. The only treatment for exostoses is surgical, and this is usually reserved for severe, symptomatic cases. Unless cold water is avoided or ear plugs are used, exostoses may recur postoperatively and necessitate reoperation.
Multiple factors predispose surfers to recurrent bouts of otitis externa. Most otitis externa is caused by damage to the external auditory canal from stagnant water in the canal. Any water sport including surfing will encourage prolonged moisture in the ear. Trauma to the thin epithelial lining by foreign bodies or high pressure can also contribute to infection. Trauma, chronic exposure to moisture, and exostoses make otitis externa a common ailment among surfers.
Common infectious organisms include Pseudomonas aeruginosa and Staphylococcus aureus. Fungi such as Aspergillus and Candida species can also contribute. Most otitis externa can be empirically-treated with topical antibacterial drops containing either quinolones, neomycin, polymyxin B, or aminoglycosides. Some preparations contain hydrocortisone, which can help reduce inflammation. Treatment usually lasts for 5 to 7 days, although some cases may need treatment up to 2 weeks . Systemic antibiotic therapy is recommended for persistent cases, if otitis media is also present, or if spread beyond the ear canal is suspected. Antifungal treatment is indicated when fungal infection, more commonly seen in diabetic patients, is confirmed either microscopically or by culture. For patients with frequent bouts of otitis externa, a discussion of preventive strategies is warranted. Such options include the use of ear plugs while in the water or the routine otologic administration of isopropyl alcohol/acetic acid mixtures to help dry the ear canal after surfing.
Tympanic membrane rupture
Tympanic membrane (TM) rupture usually occurs when either the surfer is struck by a strong wave directly in the head, or the surfer contacts the water surface with sufficient force after a fall. Lowdon et al.  and Nathanson et al.  report that TM rupture represented 6% and 7% of all injuries in their studies, respectively. TM rupture can present with ear pain, conductive hearing loss, tinnitus, vertigo, and bloody otorrhea  It is diagnosed on otoscopic examination. Most ruptures of the tympanic membrane will heal spontaneously. Antibiotic therapy is only indicated if concomitant infection is present .
The patient should be counseled to keep any foreign material, including water, out of the ear. This usually means that the patient should avoid surfing until the perforation is healed. If necessary, molded earplugs can be used to keep water out during the healing process . Like most otologic injuries, the incidence of TM rupture can be prevented by wearing earplugs. A helmet may also provide additional protection.
Surfing is an exciting sport enjoyed in many coastal communities around the globe. Participants are prone to various conditions ranging from acute injuries to conditions borne from chronic environmental exposure. Lacerations, contusions, sprains, and fractures are the common types of acute traumatic injury. Injury from the rider's own surfboard is the prevailing mechanism of injury. Surfer's myelopathy is a newly described condition, typically in novice surfers that can lead to paraparesis or paraplegia. Interaction with marine animals may lead to injury through envenomation. Exposure to jellyfish and other nematocyst-containing larvae can cause a reaction known as seabather's eruption. Stingrays and coral reefs present further hazards to the surfboard rider. Infection of wounds is often seen and should be treated with fluoroquinolones or third-generation cephalosporins to cover Vibrio species, along with Staphylococcus and Streptococcus species. Otologic sequelae of surfing include auditory exostoses, ruptured TM, and otitis externa.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
1. Nathanson A, Haynes P, Galanis D: Surfing injuries.Am J Emerg Med
2.•• Mendez-Villaneuva A, Bishop D: Physiological aspects of surfboard riding performance.Sports Med
One of the only studies assessing fitness level of surfers.
3. Lowdon BJ, Pateman NA, Pitman AJ: Surfboard-riding injuries.Med J Aust
4.•• Sunshine S: Surfing injuries.Curr Sports Med Rep
Comprehensive recent review of surfing injuries.
5. Kim JW, McDonald R, Rubsamen PE, et al.
: Surfing related ocular injuries.Retina
6. Lawless M, Porter W, Pountney R, Simpson M: Surfboard-related ocular injuries.Aust N Z J Ophthalmol
7.•• Thompson TP, Pearce J, Chang G, Madamba J: Surfer's myelopathy.Spine
Recent case series describing a new disorder in surfers.
8. Auerbach PS: Marine envenomations.N Engl J Med 1991
9.•• Robles LA: Cervical spine injuries in ocean bathers: wave-related accidents.Neurosurgery
Recent addition to the medical literature.
10. McGoldrick J, Marx JA: Marine envenomations, part 1: vertebrates.J Emergency Med
11. Otten EJ, Blomkalns AL: Venomous animal injuries. In Rosen's Emergency Medicine: Concepts and Clinical Practice, edn 5. Edited by Marx JA. St. Louis: Mosby; 2002:799.
12. Freudenthal AR, Joseph PR: Seabather's eruption.N Engl J Med
13. Wong DE, Meinking TL, Rosen LB, et al.
: Seabather's eruption.J Am Acad Dermatol
14. Kumar, S, Hlady GW, Malecki JM: Risk factors for seabather's eruption: a prospective cohort study.Public Health Rep
15. Burnett JW: Seabather's eruption.Cutis
16. Nichols AW: Nonorthopedic injuries in the aquatic athlete.Clin Sports Med
17. Kroon DF, Lawson ML, Derkay CS, et al.
: Surfer's ear: external auditory exostoses are more prevalent in cold water surfers.Otolaryngol Head Neck Surg
18. Deleyiannis FW, Cockcroft BD, Pinczower EF: Exostoses of the external auditory canal in Oregon surfers.Am J Otolaryngol
19. Wong BJF, Cervantes W, Doyle KJ, et al.
: Prevalence of external auditory canal exostoses in surfers.Arch Otolaryngol Head Neck Surg
20. Sander R: Otitis externa: a practical guide to treatment and prevention.Am Fam Physician
21. Richmond DR, Yelverton JT, Fletcher ER, et al.
: Physical correlates of eardrum rupture.Ann Otol Rhinol Laryngol
1989, 98(Suppl 140)
22. Kerr AG: The effects of blast on the ear.J Laryngol Otol
23. Hartwick R, Callanan V, Williamson J: Disarming the box jellyfish: nematocyst inhibition in Chironex fleckeri.Med J Aust
24. Burnett JW, Rubinstein H, Calton GJ: First aid for jellyfish envenomation.South Med J
25. Exton DR, Fenner PJ, Williamson JA: Cold packs: effective topical analgesia in the treatment of painful stings by Physalia and other jellyfish.Med J Aust
26. Thomas CS, Scott SA, Galanis DJ, et al.
: Box jellyfish (Carybdea alata) in Waikiki: their influx cycle plus the analgesic effect of hot and cold packs on their stings to swimmers at the beach: a randomized, placebo-controlled, clinical trial.Hawaii Med J
27. Nomura JT, Sato RL, Ahern RM, et al.
: A randomized paired comparison trial of cutaneous treatments for acute jellyfish (Carybdea alata) sting.Am J Emerg Med