Windsurfing Injuries

Added Awareness for Diagnosis, Treatment, and Prevention

Daryl A. Rosenbaum, MD
Thomas E. Dietz, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 5 - MAY 2002

In Brief: With proper training and safety precautions, windsurfing is a relatively safe sport, but its unique equipment and unpredictable environmental conditions can produce serious injuries. Clinicians are likely to see patients with ankle injuries, tarsometatarsal injuries, or anterior shoulder dislocations sustained during falls; chronic low-back pain from stresses placed on torsos; and skin lacerations and sun damage. The physician's role in preventing injuries is to stress safety, especially using equipment properly and wearing protective gear and sunscreen.

A combination of sailing and surfing, the sport of windsurfing (also called boardsailing) originated in the late 1960s and enjoyed a surge in popularity in the 1980s when it became an Olympic sport. Currently, there are about 1.2 million participants in the United States. The average windsurfer is 37 years old, but about 10% are older than 50. Almost half (40%) are women, and nearly 90% are college-educated. Windsurfing requires an average sense of balance and more finesse than raw brute strength. About 80% of windsurfing is done on lakes, rivers, and bays in light to moderate wind. ¹

Basic Equipment

The main piece of equipment is an 8- to 12-ft-long plastic or fiberglass-covered board with fins on the underside of the stern (figure 1). Synthetic sails of varying sizes can be attached to a free-pivoting mast that rises from the center of the board. The windsurfer holds on to a chest-high boom. An optional harness attached to the boom supports the waist, allows the body weight to counteract the pull of the wind, and relieves pressure on the arms and lower back. The feet can be inserted under straps at the rear of the board for improved stability and steering in high winds. Additional equipment includes a wet or dry suit, footwear, helmet, and personal flotation device; however, there are no specific laws or guidelines dictating their use.

Incidence and Types of Injuries

Despite routinely reaching speeds of 30 mph and jumps of 10 to 15 ft, windsurfing is a relatively safe sport. One retrospective study² found approximately 1 injury per 1,000 sailing days. However, because of the unique equipment used and the often extreme conditions of wind and water, serious injuries do occur.

The most frequently affected body areas of windsurfers are the lower extremities (44.6% of acute injuries), the upper extremities (18.5%), the head and neck (17.8%), and the trunk (16%). The most common types of injuries include sprains (26.3%), lacerations (21.2%), contusions (16.2%), and fractures (14.2%). Less common occurrences include dislocations, disk herniations, jellyfish stings, hypothermia, near-drowning, and concussions.²

Lower Extremities

Injuries to the ankles and feet can be quite severe, and nearly half are fractures or ligament damage.² About 75% of fractures and ligament injuries result from falling while the foot is engaged in the strap.² Being thrown off the sailboard with the strap still across the dorsum of the foot can apply significant counteractive forces across the ankle and foot (figure 2).

Lisfranc dislocation or fracture. The common traumatic mechanism of the footstrap also mandates high suspicion for a Lisfranc dislocation or fracture in any windsurfer who has midfoot pain, especially if pain is reproduced by passive pronation and abduction of the forefoot while the hindfoot is fixed (see "A Lisfranc Fracture-Dislocation From Windsurfing"). Weight-bearing radiographs in three planes (anteroposterior [AP], lateral, and 30° oblique) should be obtained to look for the characteristic findings.

The x-ray findings for Lisfranc fracture can be subtle and are missed in as many as 20% of cases³. Comparison views of the other foot can help the clinician distinquish between subtle and normal x-ray findings. If initial radiographs appear negative, vigilance is still required because this injury may not always be evident on plain films. Continued midfoot pain and swelling and difficulty bearing weight 3 to 5 days postinjury demand further imaging, such as a computed tomography scan.⁴

Some minor tarsometatarsal sprains may be treated nonsurgically with casts, but Lisfranc injuries usually require referral to an orthopedic surgeon. Most authors feel that surgical fixation is necessary to achieve precise anatomic reduction.^3-6 Early and accurate diagnosis is the best way to prevent long-term morbidity.

Upper Extremities

The classic windsurfing injury of the upper extremity is a shoulder dislocation. The usual mechanism involves hanging on to the boom during a fall, which can anteriorly dislocate the humeral head. We have not seen a posterior shoulder dislocation from windsurfing.

On the scene, an attempt at reduction can be made before muscle spasm sets in, but only if the care provider is experienced with shoulder injuries. It is important to perform a complete neurovascular exam of the injured limb, including an assessment of deltoid contraction, before reduction is attempted because an associated axillary nerve injury may be present. If reduction is not attempted, the arm should be immobilized in the adducted position before transporting the patient to emergency care.

Common Skin Damage

Other than sprains, the most common injury suffered by windsurfers is a laceration, usually to the head or lower extremity.^2,7 The usual cause is from contact with the fins or other parts of the equipment, but lacerations can also result from hitting rocks, coral, shells, and other underwater objects. To avoid infection, athletes should avoid exposing wounds to salt water for at least 48 hours after repair to allow time for a waterproof and bacteria-resistant epithelial bridge to form.⁸

Jellyfish pose another hazard. Of the 73 athletes who responded to a questionnaire, 26% had been stung by a jellyfish while windsurfing.⁷ Jellyfish stings should be immediately rinsed with sea water. Avoid using fresh water or rubbing the affected area; both may cause remaining nematocysts to discharge venom. Follow with a vinegar rinse to interrupt envenomation, then apply a cool compress and a topical preparation such as hydrocortisone cream to soothe the area.⁹

Back Pain

Low-back pain is one of the most common chronic conditions that affect windsurfing athletes. More common in longboard sailors,² it seems to be aggravated by increased sailing duration in light winds,¹⁰ suggesting that maintaining a static posture of lumbar lordosis for prolonged periods may fatigue and strain low-back muscles. Especially with a longboard, repetitive "uphauling" (pulling the sail up and out of the water) may place a flexion overload on the lower back if done with poor technique. Theoretically, this flexion load could lead to a strain of the lumbar extensors or even disk disruption or herniation. Preventive measures include using a waist harness (when conditions and experience allow) or doing a pelvic tilt to relieve some of the continuous burden on the back, and strengthening the trunk muscles with exercises, such as prone leg extension.

Shortboard, high-wind sailors are not immune to low-back injury. In fact, Locke and Allen¹⁰ found an increased incidence of disk protrusions and pars interarticularis defects in a small group of elite windsurfers compared with the general population. They theorized that gusting winds and higher waves or twisted posture and fatigue put enough stress on the spine to produce pathologic changes. Prolonged hyperextension of the lumbar spine from leaning back too far in the harness could also explain the increased incidence of pars fractures.

Staying Out of Hot Water

The first and most obvious safety tip is to be prepared. Sailors should study local water currents, obstacles, wind patterns, weather, and boat traffic, and choose an area that matches their ability. A windsurfing board is considered a sailing vessel, so the athlete must follow the usual rules of sailing and respect others in the same area. Sailing with a buddy can ensure that help is available in case of injury or equipment failure.

Protective gear is another important part of windsurfing safety. Helmets help avoid lacerations, concussions, and other head trauma. Helmets designed and certified for water sports (eg, windsurfing, waterskiing, wakeboarding) have a light, impact-resistant plastic shell with a padded liner that drains water and provides adequate peripheral vision and hearing. Beginners should always wear helmets when sailing because of the risk of being struck if the mast is released during a fall. More experienced windsurfers should wear a helmet when sailing in crowded areas or when performing high-speed or aerial maneuvers. A personal flotation device is highly recommended.

The skin should also be protected from sun damage by applying a waterproof sunscreen with a sun protective factor of at least 30 an hour before exposure and every 2 hours thereafter. In addition to protecting the eyes from trauma, shatterproof sunglasses can also prevent problems from long-term sun exposure. A wet or dry suit and protective footwear such as neoprene booties or slippers can prevent many lacerations, and gloves can decrease abrasions and blisters on the hands.

The windsurfing industry has designed more rigid footstraps with increased clearance that allow for a quicker, easier exit. However, windsurfers should probably still be advised to avoid inserting their feet under the strap past the metatarsophalangeal joint.

Cognizant Care

Physicians are likely to see more windsurfing injuries as the popularity of the sport increases. The clinician's awareness of common windsurfing injuries can lead to prompt and accurate diagnosis and treatment. Physicians can help reduce injuries by promoting safe sailing habits and protective equipment use.

References

American Windsurfing Industries: Summary of available research. Available at www.awia.org/info/research.htm. Accessed March 11, 2002
Nathanson AT, Reinert SE: Windsurfing injuries: results of a paper- and Internet-based survey. Wilderness Environ Med 1999;10(4):218-225
Goossens M, De Stoop N: Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases. Clin Orthop 1983;176(Jun):154-162
Lu J, Ebraheim NA, Skie M, et al: Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study. Foot Ankle Int 1997;18(6):351-355
Arntz CT, Hansen ST Jr: Dislocations and fracture dislocations of the tarsometatarsal joints. Orthop Clin North Am 1987;18(1):105-114
Myerson M: The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am 1989;20(4):655-664
McCormick DP, Davis AL: Injuries in sailboard enthusiasts. Br J Sports Med 1988;22(3):95-97
Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, ed 3. Philadelphia, WB Saunders, 1998, pp 533, 553
Auerbach PS: Wilderness Medicine: Management of Wilderness and Environmental Emergencies, ed 3. St Louis, Mosby-Year Book, 1995, p 1335
Locke S, Allen GD: Etiology of low back pain in elite boardsailors. Med Sci Sports Exerc 1992;24(9):964-966

A Lisfranc Fracture-Dislocation From Windsurfing
A healthy, 33-year-old male windsurfer was injured when he was forcibly launched from his board and his right foot did not come free of the strap. Initially, his right foot substantially deviated laterally in relation to the midfoot, but he reflexively reached down and yanked it back toward the midline. He was assisted back to shore and was subsequently unable to bear weight on his right foot. He had no numbness or tingling, no prior injury to the right foot or ankle, and no pain in the ankle or the leg.
Examination of the right foot revealed an obvious deformity: The forefoot angulated 15° to 20° lateral to the midfoot. Moderate edema was noted over the dorsum of the foot at roughly the tarsometatarsal junctures. No ecchymosis was seen. The entire forefoot was extremely tender to palpation, but no crepitance was felt. Circulation and sensation were intact distally, and the patient was able to move his toes.
X-rays (figure A) revealed a Lisfranc fracture of the second metatarsal base and a dislocation of the first, third, fourth, and fifth metatarsals. On the AP view of a healthy foot, the lateral border of the base of the first metatarsal should align with the lateral surface of the medial cuneiform, and the medial aspect of the second metatarsal should align with the medial border of the middle cuneiform. Disruption of these relationships and the presence of a fracture fragment between the bases of the first and second metatarsals indicate a Lisfranc fracture-dislocation.
On the oblique view, diagnostic findings included disruption of the alignment between the lateral surface of the third metatarsal with the lateral border of the lateral cuneiform, and the medial surface of the fourth metatarsal with the medial border of the cuboid. On the lateral view, a Lisfranc fracture-dislocation may appear as dorsal displacement of the metatarsal bases compared with the tarsal bones.
The patient was taken to the operating room for closed reduction and percutaneous pinning of the fracture and dislocations.

FIGURE A. An anteroposterior radiograph (left) in a 33-year-old male windsurfer shows obvious disruption in the normal alignment between the lateral surfaces of the base of the first metatarsal and the medial cuneiform and that of the medial surfaces of the base of the second metatarsal and the middle cuneiform (arrow). This is consistent with a Lisfranc fracture. A fracture fragment (arrowhead) found between the bases of the first and second metatarsals is also a characteristic finding. A 30° oblique view (center) suggests abnormal alignment between the lateral surface of the third metatarsal and the lateral aspect of the lateral cuneiform (arrow). The medial border of the fourth metatarsal and the medial border of the cuboid (arrowhead) has also been disrupted; these usually form a straight line. A lateral view (right) shows dorsal displacement of the bases of the first and second metatarsals in relation to the cuneiforms (arrow).

Dr Rosenbaum is a team physician at Western Carolina University in Cullowhee, North Carolina, and Dr Dietz is a physician at Hood River Emergency Physicians in Hood River, Oregon. Address correspondence to Daryl A. Rosenbaum, MD, c/o Carolina West Sports Medicine, 57 Eastgate Dr, Sylva, NC 28779; e-mail to rosenbaumdaryl@hotmail.com.

Disclosure information: Dr Rosenbaum and Dr Dietz disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned for an unlabeled use.

RETURN TO MAY 2002 TABLE OF CONTENTS