Marc Darrow, MD, JD.
Over the years we have seen many shoulder problems. Surfers are a particular group of interest in that many surfers have problems, not in one shoulder, but in both shoulders. While there are many articles on shoulder pain, it is surprising that there is not more specialized information available to the surfer about their shoulder injury. A January 2021 review article (1) from an international team of specialists points this out: “Chronic shoulder complaints are frequently reported amongst surfers, though literature researching its pathophysiology and prevention is scarce.” The researchers then wrote that their review would then provide an overview of the current literature. Here is the summary of their overview:
“Wave surfing will debut in the next Olympic Games and is increasingly popular as a sport. . .In surfers with shoulder complaints, external rotation range of motion and external rotation strength are impaired. Scapulothoracic dyskinesis (abnormal scapula motion, shoulder instability, shoulder impingement) may occur and subacromial pain syndrome may coincide.”
Further research should address potential pectoralis minor shortening (Let’s explain: One characteristic among many of a “shortened” muscle is that the muscle is tight and possibly in spasms. Muscle spasm can be a sign of tendon and ligament weakness as the muscle is trying to stabilize a joint instead of doing its regular job of powering the joint. Ligaments provide the shoulder with stability, tendons are the muscles attachments to the bones that help the muscle provide power. If the muscle is in spasm and “shortens” the muscle will then pull on the tendon, tearing at it. The shoulder then becomes weak and painful.
The review paper also points out that muscle shortening can lead to “aberrant scapular tilt” and lateral rotation of the scapula. The scapula has moved out of its natural position and can then cause a problem of “scapular winging.” The surfer’s shoulder can also be characterized by external rotation deficit (limited range of motion).
Paddling, a cause of Surfer’s Shoulder
Paddling can cause an overuse injury in the shoulder. Typical of overuse injury is the inflammation and pain come with shoulder movement. As mentioned above, muscles can become shortened when they are injured, in spasm, or when the atrophy. Surfer’s can also develop bursitis of the shoulder an shoulder impingement.
Shoulder Impingement Care
We see many people who continue with their sport or surfing through their shoulder pain, sometimes they continue through a severe shoulder pain. Surfers may complain about pain when they extended their hands over their head during swimming or paddling out. The pain is now beyond the control of RICE (rest, ice, compression, and elevation) and self-medicating with anti-inflammatory medications. When you got to the point where you may have to stop surfing and swimming, this is when you decided to get medical care. Medical care may not have been to your likening. You may have not liked the suggestion your doctor gave you to stop activities for a while to see if your shoulder heals on its own. You may have liked it worse when after a long bout of rest, you tried a little swimming and your shoulders still hurt.
When you returned to your doctor after the rest period and want to try something else to help accelerate your healing you may have been told to go to physical therapy to see if that works. You can also try a cortisone injection.
Once pain is determined to come from the subacromial space of the shoulder, that is the area of the rotator cuff tendons and the subacromial bursa, then shoulder impingement is often diagnosed. The impingement occurs when the Acromion’s underside, presses against the rotator cuff tendons, wear and tearing at them. When a patient comes into our office we will perform a detailed physical examination of the shoulder looking for pain generators. Spots on the shoulder that elicit a pain response when pressed. Typically these are the spots of damage.
A whole shoulder injury
The challenges of proving patient care for the surfer with shoulder pain is highlighted in a March 2022 paper (2) from the University of Hawaii. The authors suggest: “Unfortunately, there is limited evidence available to guide treatment due to the frequent occurrence of concomitant pathology (shoulder pain is typically not limited to an isolated injury but a combination of many) and a dearth of well-designed randomized controlled trials. Nonoperative management of subscapularis tendon tears is similar to that involving other parts of the rotator cuff. Options include activity modification, analgesics and anti-inflammatories, corticosteroid injections, and physical therapy. . . Older, less active patients with chronic degenerative tears are generally considered candidates for conservative treatment. . . Failure of attempted nonoperative management is an indication for surgery.”
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References
1 Langenberg, L.C., Lima, G.V., Heitkamp, S.E., Kemps, F.L.A.M., Jones, M.S., Moreira, M.A.D.A.G. and Eygendaal, D., 2021. The Surfer’s Shoulder: A Systematic Review of Current Literature and Potential Pathophysiological Explanations of Chronic Shoulder Complaints in Wave Surfers. Sports Medicine-Open, 7(1), pp.1-11.
2 Goldberg DB, Tamate TM, Hasegawa M, Kane IV TJ, You JS, Crawford SN. Literature review of subscapularis tear, associated injuries, and the available treatment options. Hawai’i Journal of Health & Social Welfare. 2022 Mar;81(3 Suppl 1):2.