Paddling Injuries by Paul E. Plumer, WEMT, NREMT-P
Wrists, elbows, and shoulders are particularly susceptible to injury in both whitewater and flatwater boating. When body movement goes beyond the normal range of motion (ROM) permitted by our anatomy, pain and disability are sure to follow. Lucky for us that they do—these governors on excess help us to recover and paddle another day.

Whether the problem derives from a use/use pattern of exercise (repetitive, relatively constant training or recreating) or from a disuse/use pattern (the weekend warrior phenomenon), overuse is usually the culprit. Contributing factors to the likelihood of injury include the individual’s level of musculoskeletal fitness, state of nutritional health, and judgment with respect to his or her own limitations.

Incidence

In the Year 2000 Whitewater Injury Survey 1 investigators analyzed data from 319 hard-boat respondents (canoeists and kayakers) to an extensive questionnaire. The survey examined the demographics of injury distribution along lines of gender, boat preference, water class rating, and the average number of days spent paddling per year. Injuries were classified as acute (an immediately discernible injury at the time of the incident) or chronic (a slower onset of symptomology produced by repetitive overuse). The investigators found that injuries to the wrist, forearm, elbow, and shoulder occurred with the greatest frequency. The majority of all of the injuries reported were above the height of the waist and were caused either by direct trauma or by overuse.

Canoeists - Canoeists beat out kayakers in the forearm/elbow department, chronic category. The shoulder was the most common location for kayaker injury in both the acute and chronic categories. And the incidence of injury overall was directly proportional to the frequency of exposure. That is, the more you do it, the more likely you are to get hurt. Makes sense. Okay, whose turn is it next?!

In an investigation of wrist tenosynovitis (inflammation of the tendon sheaths and synovial structures), researchers looked at a marathon canoe racing population and found that 23% of the paddlers developed the malady 2. They speculated that the high incidence of wrist trouble in this setting may be due to the excessively variable range of motion demanded of the joint during the work of keeping boats with such little primary and secondary stability tracking efficiently, especially given the vicissitudes of wind and water. Further, they theorized that willful reduction in ROM by the paddler while engaged in the activity would probably reduce the incidence.

Kayakers - In a more recent study on the epidemiology of whitewater kayaking injuries specifically, data was collected from 392 respondents 3. Bumping into a fixed object was the most common cause of injury in this study and the second most common cause was a toss up between overuse and traumatic stress. Again, the upper extremity, and firstly the shoulder, was the most common location of injury. Echoing findings in Stano and Schoen’s study 1, incidence correlated directly with exposure. Interestingly, 87% of the injuries occurred when the boater was still in his or her kayak. Perhaps those of us lacking a bombproof, combat roll can trot this statistic out in times of need to mitigate feelings of inadequacy and boost a flagging aqua-self-esteem!

Upper extremity injuries are the focus of this article. For the sake of thoroughness however, we ought to mention a survey of 417 canoeists from the Japan Canoeing Association in which the most frequent complaint was lower back pain 4. Shoulder pain followed closely, then elbow and wrist discomfort in that order of statistical frequency. We will leave the lumbago discussion for another article.

Rafting - Also, let’s not neglect the rafting industry. In a survey of 200 injuries of commercial rafting customers from 1995-1997 on the New, Gauley, Cheat, and Shenendoah rivers, 51.3% of the incidents were the consequence of in-raft collisions 5. The injuries were soft tissue trauma and fractures involving the head, face, torso, and upper limbs. 40.3% of the injuries occurred in the water after clients had fallen out of the rafts. Investigators recommended improved head protection, assigning fewer people to each raft, and employing greater discretion when deciding whether to paddle or to portage.

Injuries

Recall that ligaments connect bone to bone and that tendons attach muscle to bone. Tendons are a continuation of the outermost layers of muscle tissue, a connective tissue extension that anchors to the bone. In synovial joints articulating bones are separated by a cavity that contains the lubricating, synovial fluid. Bursae are flattened, membranous sacs of synovial fluid which facilitate joint motion in a fashion often likened to the function of ball bearings. Tendon sheaths are essentially elongated bursae. They wrap around tendons, which are subject to the friction of flexion and extension. Tendonitis, synovitis, and bursitis all refer to inflammatory states where normal synovial function has been disturbed. The result is increased tissue pressure and its associated pain and disability.
Ligaments and tendons can become stretched or disrupted altogether, producing a joint laxity that is a setup for subsequent dislocation. In rotator cuff injury the four muscles and their tendons (SITS--subscapularis, infraspinatus, teres minor, and supraspinatus) that govern shoulder circumduction are damaged.

Impingement syndromes imply entrapment or compression as a result of tissue inflammation or subluxation of a joint. Tendon, nerve, and vascular structures all have the potential for compromise under such circumstances. For example, anterior displacement of the humeral head can compress the subacromial bursae and produce a nasty bursitis.

The wrist and forearm are susceptible to tendonitis of the flexor and extensor muscles, making buttoning a shirt, turning a door knob, or brushing teeth exquisitely painful. Paddling is out of the question during a severe bout of tendonitis. Carpal tunnel syndrome can also plague the paddler. Parasthesias and pain are the result of compression or vibratory damage to the median nerve distribution of the hand. Paddlers can sometimes mitigate the symptoms by loosening their paddle grip or frequently varying their hand position.

Finally, the dreaded shoulder injury. Tendonitis can befall any or all of the rotator cuff tendons mentioned above as well as the biceps and deltoid tendons, sometimes incapacitating the most heroic paddler. Disruption of the glenohumeral joint can cause shoulder dislocation--of the anterior variety in the majority of cases--the result typically of an indirect force that brings a levering action to bear on the joint. Posterior dislocations are statistically less frequent occurrences and usually require a direct mechanism to happen. One possible scenario for a posterior event in a canoeist’s off-side shoulder would be blade impact with an immovable rock while executing a cross draw stroke, especially if the joint had pre-existing laxity.

Add assorted fractures caused by direct trauma and the list would lengthen. Regardless of the etiology a reasonable description of an injury at the tissue level might go something like this: Cells sustain damage. Cell membrane integrity is lost. The usual boundaries of our bodily compartments (intracellular, interstitial, intravascular) in the zone of injury are altered. Fluid volume translocates and the attendant swelling increases local pressure enough to engage peripheral pain receptors. Spinothalamic neurological pathways send a message north and "ouch" registers in the sensory cortex. The cerebral motor cortex responds by restricting subsequent range of motion; that is, the patient protectively self-splints. Pain, as it turns out, has a positive side. It is a physiological response that helps diminish the probability of continued tissue damage. It persuades us to be still.

Treatment and Prevention

During the acute period of the injury, treatment includes pain-free activity (PFA), perhaps splinting, rest, regular icing of the area, and medications such as NSAIDS and aspirin as necessary. People with underlying renal, hepatic, or hematologic disease beware: though in common use, these medications are not benign. When in doubt it is wise to consult a reliable medical authority before self medicating. More medication, though tempting, is not necessarily better. In cases of intractable muscle spasm, sometimes reported in shoulder dislocations, sedation with a benzodiazepine may be useful.

Back to icing for a moment. There is concern about the vascular effects of excessive icing. A balance must be struck between the beneficial effects of reduced swelling and thermally induced analgesia on the one hand and, on the other hand, the presumed deleterious effects of reduced blood flow and the resultant tissue hypoperfusion. Physical therapists recommend icing three times a day for brief periods, 15-30 minutes, with ample time in between to fully restore perfusion to the injury site.

Long-term recovery--whether two weeks, two months, or two years—hinges on the individual’s patience and understanding of the reparative process. A recovering paddler should exercise carefully but persistently as directed. Recovery may require new levels of self consciousness about one’s body and health. The paddler may need to become more deliberate in his or her physical activity than ever before. This amount of restriction may be difficult to swallow. The recovery process will present as much psychological challenge as physical.

Injury Prevention

Regarding prevention, all the usual advice applies: healthy diet, regular exercise, psychic well-being. Paddlers need to remember to stretch before and after they paddle. They must heed the back, too. It is the orthopedic dumping ground for stress. They should choose an exercise regimen designed to promote spine flexibility so they don’t end up with a whopping shoulder tendonitis because they were compensating for an overly stiff back. It is wise to develop a routine that addresses as many ranges of motion for each joint as possible. Weights in moderation may be useful. Varying thicknesses of surgical tubing are great workout devices. Hydration is essential. Muscles love water.
Some modification in paddling technique or a boat’s outfitting may help. Having another boater watch a paddler on the river and offer advice may also be useful. Who knows, his or her ideas may furnish a pearl of, wisdom that will be the aquatic equivalent to removing the wallet from the back pants pocket while driving and having back pain disappear overnight!

Modify Your Technique

•    Recreational canoeists should learn to sway at the waist during forward strokes on the flats.
•    Wrists should be held in check to limit erratic motion and eccentric loading on the flexors and extensors.
•    Kayakers should try leaning a bit more forward on the deck, to lead with the shoulders. They should also adjust hand position on the paddle shaft, wider apart to engage more shoulder power and give wrist tendons a break.
•    Canoeists can try a shorter paddle. It will instantly reduce the threat to the shoulder of the upper hand. What may be lost in low bracing capacity is worth giving up for the comfort and added safety.

Paddlers in the recovery phase after an injury, but out there paddling nonetheless, might try a smaller blade, one that will move less water but be more comfortable. Another long-range strategy for the prudent paddling life is to become a bilateral paddler. Easier said than done, but making both sides the "on side" may be advantageous.
The troubleshooting list is endless, of course. The injury-prone should talk with those paddlers who seem to make their moves effortlessly, who move downriver with the greatest of ease. They know something about mind and body that the rest of us may not. Maybe they’ll share it. In the meantime, we should listen to pain. It, too, is urging us to find a better balance. Happy paddling. Be well. WMA

Paul E. Plumer, WEMT, NREMT-P, WMA instructor, is co-founder of the Maine Institute of Medicine (www.miom.net) and has been associated with WMA for many years. He is also the president of the Penobscot Paddle and Chowder Society, a Maine canoe club. He has been paddling for three decades - whitewater open boating in Maine and Quebec and expedition tripping from Labrador to the Yukon.

1.    Schoen, R., Stano, M. (2000). Year 2000 whitewater injury survey. Retrieved July 2, 2002. (online). http://www.geocities.com/injury_survey/drawing.htm
2.    Du Toit, P., Sole, G., Bowerbank, P., Noakes, T. D. (1999). Incidence and causes of Tenosynovitis of the wrist extensors in long distance paddle canoeists. British Journal of Sports Medicine, 33, 105-109.
3.    Fiore, D. C., Houston, J. D. (2001). Injuries in whitewater kayaking. British Journal of Sports Medicine, 35, 235-241.
4.    Kameyama, O., Shibano, K., Kawakita, H., Ogawa, R., Kumamoto, M. (1999). Medical check of competitive canoeists. Journal of Orthopedic Science, 4, 243-249.
5.    Whisman, S. A., Hollenhorst, S. J. (1999). Injuries in commercial whitewater rafting. Clinical Journal of Sports Medicine, 9, 18-23.