Surfer's Neck

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Surfer's Neck - Clinically Relevant Anatomy

Neck Upper Back.png

Surfing is enjoyed by many people around the world. Surfing involves dynamic moves on an unstable surface needing good body strength, coordination and balance.A common problem for surfers is Surfer's neck (and Surfer's Back)

The muscle, facet joints, foramina of vertebrae, nerves and fascia are some of the structures that may be involved in the pain mechanism. Fortunately these niggles can often be rectified with some good manual therapy techniques, correction of surfing technique (if needed) and a good rehabilitation program incorporating stretches, strengthening and co-ordination and postural training.

Mechanism of Injury / Pathological Process

Neck Pain is a common niggle for surfers and is often caused by overuse.

Common causes may be attributed to

  • Large amount of time spent in the prone position with neck in extension. Prolonged extension of the cervical facet joints in a closed packed position (whilst paddling) increases the demands on the structures of the upper spine and associated soft tissues.
  • Inadequate extension in the thoracic, increasing the demands of extension on the cervical spine.
  • Turning, cutting, and twisting movements of the spine and neck predispose the neck to overuse injury.
  • Insufficient flexibility and strength of muscles in upper kinetic chain and spine.
  • Surfing Hawaii.jpg
    Poor surfing technique eg with paddling
  • Poor postural alignment predisposing injury
  • Poor breathing technique ie upper chest, neck muscle breathing pattern not diaphragm breathing.

Clinical Presentation

Surfer's Neck is a very common surfer's condition usually related with paddling, but neck pain can also appear after a wipeout. The cervical spine is held in extension for long periods of time. Consequently the muscles in the back of the neck, upper back, and lower back are in constant contraction, causing tension and muscular shortening of the trapezius and other neck muscles.

A typical presentation would be a soreness will only arrive a few hours after the surf session, when the neck muscles go into spasm. Often if left unattended to the pain can be more complex, as the neck ache may start to involve associated tendons, ligaments, muscles, bones and even nerves. These can cause more severe symptoms. eg restricted ROM, cervical spine radiculopathy

Outcome Measures

Neck Disability Index

Neck Pain and Disability Scale

Tragus to Wall Test (if postural changes noted)

Hi-Low Breathing Assessment

Management / Interventions

Exercise treatment appears to be beneficial in patients with neck pain. There is some evidence to support muscle relaxants in acute neck pain associated with muscle spasm, conflicting evidence for epidural corticosteroid injections for radiculopathy, and weak positive evidence for cervical facet joint radiofrequency denervation.[1]

Physiotherapy Treatment

Manual Therapy

As a physical therapist you have lots of good Manual Therapy skills to improve the client's condition. Work on the small suboccipital extensors and flexors, cervical spine deep muscles, and any tight muscles in chest, shoulder and upper back. Often this will include mobilisation of a stiff upper thoracic segment.

Massage image.jpg

Include techniques from: Maitland mobilisations, massage ball techniques ( a ball release exercises on the upper torso can help alleviate the tension in the area around the neck), soft tissue release, trigger pointing, Kaltenborn techniques, Active Release Techniques, Stretching including PNF, contract relax and reciprocal inhibition etc.

Stretches

Include some or all of the following stretches and self mobilisations of cervical spine (see image)

Sternocleidomastoid, upper and middle trapezius, suboccipital extensors, cervical spine flexors and extensors ( chin tucks,neck flexor stretches), anterior chest muscles and thoracic spine.

Cervical spine exercises.png

Yoga or Tai Chi are also great to work on flexibility

Stability and endurance

Work on the stabilizers of the cervical spine and shoulder girdle. eg upper cervical flexors, spinal extensors, scapular (scapular retractors)and shoulder stabilisers.

These will provide stability for the neck and shoulder girdle, critical for its performance and the protection of the neck. They provide stability and support to the neck throughout movement and provide important protection from the high forces placed on the body during surfing.

Pilates is also a great way to get spinal stabilisation and core strength.

Surfing Technique Guidance

Instruct on ways to lessen cervical extension in paddling. eg teach how to engage whole upper spine when extending neck not just cervical spine, instruct on need to mobilise thoracic spine so this can occur. Check that muscles have sufficient flexibility, strength and co-ordination for surfing postures. Rehabilitate as needed.

NB seek out surfing coaches if required

Breathing Pattern

Teach correct diaphragm breathing and control instead of upper chest and neck muscle activation with breathing, upper chest breathing creates excess tension in the cervical muscles. A 2017 study noting that "Dysfunctional breathing (DB) has been linked to health conditions including low back pain and neck pain and adversely effects the musculoskeletal system"[2]. Another study noted the importance of diaphragmatic breathing on functional movement "Inefficient breathing could result in muscular imbalance, motor control alterations, and physiological adaptations that are capable of modifying movement.....Future research is needed to validate breathing re‐education programs and the role they have in treating pain disorders, preventing injury, and improving movement patterns".[3]

Postural Education

Poor-posture-examples.jpg

Check for postural abnormalities eg head forward posture, thoracic kyphosis (see diagram). If the classic head forward, thoracic kyphosis posture exists surfing (and paddling) will easily cause an injuries/pain to neck. Train the client in proper alignment and mobilise thoracic spine and strengthen cervical spine as appropriate. A recent study reporting that a forward head posture is a factor that leads to the development of pain through poor postural alignment[4].

Differential Diagnosis

Be vigilant in your checking re recent trauma or red flag symptoms

Surfer's myelopathy, Surfer's myelopathy is a atraumatic thoracic/conus medullaris myelopathy with only a 42% neurological recovery rate, almost uniformly affecting young, healthy, novice surfers who have no pre-existent spinal disease. Symptoms usually start with back pain and rapidly progress to complete or incomplete myelopathy. Emergency physicians must be better informed about surfer's myelopathy. Novice surfers and instructors should be educated on the early signs and symptoms of this condition.[5]

Vertebrae injury or fracture An retrospective analysis of surfer's in Australia found an incidence of .5% and .3% respectively[6] A multitude of different injuries occur in the cervical spine and depend on the position the surfer is in when they strike the sea floor relative to the force vector of the wave. Flexion, extension, axial load, rotation, and a variety of different combinations may result in fractures, dislocations, or spinal cord injuries (predominantly contusions).[7] Make sure to include in subjective examination recent trauma.

Spinal cord injury - less common, spinal cord injuries and cervical fractures are certainly more devastating and occur when athletes collide with the seafloor.  As the wave rider is preparing to catch the crest of the next wave, they should consider the types of waves, how they are formed, and the mechanism of injury that can occur with the seafloor when thrown from the board (ie watch out for huge, unpredictable waves). Clinicians seeing a client presenting with head trauma that occurred during wave riding need to be aware of these environmental risks as well as the demographic risks that may predispose unique injuries. It becomes even more important in wave-riding sports where equipment and the ocean are easily accessible and no experience is required (AKA tourists),[8]

Surf cold.jpg

Conclusion

The International Surfing Association estimated 23 million people participated in surfing worldwide in 2014[8]. Help keep them happy with some good treatment and rehabilitation.

The image of the surfers in Norway looks a bit keen to me!

References

  1. Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. InMayo Clinic Proceedings 2015 Feb 1 (Vol. 90, No. 2, pp. 284-299). Elsevier. Available from: https://www.mayoclinicproceedings.org/article/S0025-6196(14)00833-7/fulltext (last accessed 18.9.2019)
  2. Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R. Development of a screening protocol to identify individuals with dysfunctional breathing. International journal of sports physical therapy. 2017 Oct;12(5):774. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685417/ (last accessed 20.9.2019)
  3. Bradley H, Esformes JD. Breathing pattern disorders and functional movement. International journal of sports physical therapy. 2014 Feb;9(1):28. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924606/ (last accessed 20.9.2019)
  4. Kim DH, Kim CJ, Son SM. Neck pain in adults with forward head posture: effects of craniovertebral angle and cervical range of motion. Osong public health and research perspectives. 2018 Dec;9(6):309.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296804/ (last accessed 20.9.2019)
  5. Freedman BA, Malone DG, Rasmussen PA, Cage JM, Benzel EC. Surfer's myelopathy: a rare form of spinal cord infarction in novice surfers: a systematic review. Neurosurgery. 2015 Oct 30;78(5):602-11.Available from: https://www.ncbi.nlm.nih.gov/pubmed/27082966 (last accessed 18.9.2019)
  6. Meir R et al. An investigation of surf participation and injury prevalence in Australian surfers: a self-reported retrospective analysis. Gosford Australia Southern Cross University ePublicatio[email protected]; 2011 Available from:https://epubs.scu.edu.au/cgi/viewcontent.cgi?article=1901&context=hahs_pubs (last accessed 18.9.2019)
  7. Dimmick S, Sheehan P, Brazier D, Anderson SE. Injuries sustained while surfboard riding. Skeletal radiology. 2013 Apr 1;42(4):463-5. Available from: https://link.springer.com/article/10.1007/s00256-012-1536-9 (last accessed 18.9.2019)
  8. 8.0 8.1 Falconi A, Flick D, Ferguson J, Glorioso JE. Spinal cord injuries in wave-riding sports: the influence of environmental and sport-specific factors. Current sports medicine reports. 2016 Mar 1;15(2):116-20. Available from:https://journals.lww.com/acsm-csmr/fulltext/2016/03000/Spinal_Cord_Injuries_in_Wave_Riding_Sports___The.17.aspx?exportImagesToPpt=true (last accessed 20.9.2019)