Twenty-Year Analysis of Surfing Head and Neck Injuries Presenting to United States Emergency Departments Showed a Decrease in Overall Injuries Despite Steady Concussion Rates

Abstract

Purpose

To analyze the etiology, diagnosis, and incidence of head and neck (HN) injuries among ocean surfers.

Methods

The National Electronic Injury Surveillance System database was queried for surfing HN injuries presenting to United States emergency departments (EDs) between January 2003 and December 2022. Date of presentation, age, sex, race, injured body part, injury diagnosis, and disposition, as well as a brief injury narrative, were included in the data. National estimates (NEs) were calculated using the associated statistical weight of the reporting hospital.

Results

A total of 1,359 surfing-related HN injuries (NE, 90,872) were included in this study. The average age at presentation was 29.2 ± 13.8 years (range, 3 to 81 years). The most commonly specified mechanisms of injury were impact with board (NE, 48,360 [53%]) and impact with ocean floor (NE, 8,690 [10%]). Concussions represented 5% of surfing HN injuries and occurred at a higher rate (8%) in the age group younger than 20 years. There were statistically significant decreases in overall HN injuries (P < .01) (coefficient, –270; 95% confidence interval [CI], –355 to –206), lacerations (P < .01) (coefficient, –208; 95% CI, –258 to –158), and impact-with-board injuries (P < .01) (coefficient, –177; 95% CI, –327 to –117) presenting to United States EDs from 2003 to 2022.

Conclusions

Although surfing HN injury ED presentations decreased from 2003 to 2022, the rate of surfing-related concussions presenting to EDs remained steady. Concussions therefore remain a significant concern in surfing, especially among surfers under 20 years of age.

Clinical Relevance

As the sport of surfing has increased in popularity, it is important to understand the range of surfing injuries seen in EDs. HN injuries, especially concussions, should be thoroughly investigated to better understand the risks of ocean surfing, to advise athletes, and to develop effective injury prevention strategies.

Surfing is a sport that is rapidly growing in popularity, with surf industry sources indicating that the number of surfers in the United States increased by 17% during the coronavirus disease 2019 (COVID-19) pandemic and by 35% within the past decade.1, 2, 3 The expansion of surfing is no longer limited to coastal locations because wave-generating technologies have enabled the establishment of surf parks in landlocked locations around the world.³ The popularity of the sport is expected to continue to rise given that surfing appeared in the Olympic Games in 2020 and 2024 and the International Olympic Committee confirmed surfing will be included in the 2028 Olympic Games.^4,5

A survey of surfers in Australia indicated a rate of 1.79 major injuries per 1,000 hours surfed, with increased injury risk in surfers who surfed more hours, participated in competitions, and were capable of completing aerial maneuvers.⁶ However, various studies have reported epidemiologic differences based on the type of study (e.g., hospital or emergency department [ED] records vs surfer survey), suggesting that many surf injuries may be managed outside the hospital or ED setting. Outside of surfing competitions, medical trainers and physicians are generally absent when surfing injuries occur, so recreational surfers with injuries may be managed onsite by lifeguards or other surfers.^1,7 Compared with land-based sports such as soccer, football, and basketball, surfing possesses many risks particular to the aquatic setting. Previous literature has found that the risk of injury may be affected by the wave size, depth of the ocean floor, underlying reef, and wave morphology.^1,8, 9, 10, 11 A few studies have included concussions among reported surf injury diagnoses, but these did not include focused analyses such as concussion rates over time.12, 13, 14, 15, 16, 17

The National Electronic Injury Surveillance System (NEISS) database has been used by many prior studies to analyze sports-related injuries.^1,13,14,18, 19, 20 To date, 4 studies have used the NEISS database to investigate surf injuries.^2,13,14,18 Neither Klick et al.¹³ or Hager et al.¹⁴ analyzed mechanisms of injury. Both studies by Obana et al.^2,18 included mechanisms of injury, but they focused solely on upper- and lower-extremity injuries.^1,2 Head and neck (HN) injuries were not included in these studies. The purpose of this study was to analyze the etiology, diagnosis, and incidence of HN injuries among ocean surfers. We hypothesized that there would be a decrease in the number of overall HN injuries presenting to EDs.

Methods

Data Collection

Data were sourced from the NEISS database, a publicly available national database from the United States Consumer Product Safety Commission. This database includes information from 100 hospital-associated EDs that offer 24-hour services and a minimum of 6 beds. After all 5,000 United States hospital-associated EDs were stratified by geographic location, size, and ED data volume, these 100 EDs were selected as a representative probability sample of all United States hospitals. Each hospital was assigned a statistical sample weight that allowed for calculation of national estimates (NEs) and thus provided reliable and reproducible epidemiologic data.

All surfing-related HN injuries were queried between January 2003 and December 2022 as follows: (product code 1261: surfing [activity, apparel, or equipment]) AND (product code 75: head, product code 76: face, product code 77: eyeball, product code 88: mouth, product code 89: neck, OR product code 94: ear). All ages, diagnoses, and dispositions were included. Patients were stratified by age as follows: younger than 20 years, 20 to 39 years, 40 to 59 years, and 60 years or older.

Date of presentation, age, sex, race, injured body part, injury diagnosis, and disposition, as well as a brief injury narrative, were included in the data. The mechanism of injury was classified by reviewing each narrative. Mechanisms of injury were defined as impact with board, impact with other surfer, fin-associated injury, impact with sand, impact with reef/rocks, impact with ocean floor (unspecified), impact with water, other, or not specified. Impact with sand, impact with reef/rocks, and impact with ocean floor (unspecified) were combined into a single “impact with ocean floor” mechanism for some analyses. Cases classified as internal injuries to the head (product code 62 [internal injury] and product code 75 [head]) were combined with concussion cases to investigate trends over time and mechanisms of internal head injuries.

Narratives were also screened to identify surfing HN injuries and exclude injuries that were not caused by standard ocean surfing. Injuries sustained from wake surfing, skimboarding, hydro-foiling, windsurfing, kitesurfing, bodysurfing, stand-up paddleboarding, boogie boarding/bodyboarding, and electric surfboard riding were excluded. Nonsurfers injured by surfers were excluded. Injuries that occurred outside of the ocean (e.g., wave pools) were excluded.

Statistical Analysis

Statistical analyses were performed using RStudio software (version 2023.06.0+421; Posit PBC). Linear regressions were applied to investigate NEs for overall injuries, mechanisms of injury, and concussions over time. To account for the effects of the COVID-19 pandemic, similar analyses were conducted excluding data from 2020. The level of statistical significance was set at P < .05. NEs were calculated by multiplying the associated statistical weight of the reporting hospital by each queried raw data point.

Results

Between January 1, 2003, and December 31, 2022, there were 1,795 cases of ED-diagnosed surfing-related HN injuries (NE, 112,048). After review of narratives, application of inclusion and exclusion criteria resulted in 1,359 cases (NE, 90,872) included in the analysis. The average age at presentation was 29.2 ± 13.8 years (range, 3 to 81 years), and 81.2% of patients were male patients. There were 912 white patients (NE, 62,101 [68%]), 319 patients of unspecified race (NE, 20,087 [22%]), 74 patients of other race (NE, 4,807 [5%]), 41 Asian patients (NE, 3,174 [3%]), 11 Black/African American patients (NE, 564 [1%]), and 2 Native Hawaiian/Pacific Islander patients (NE, 139 [0%]). Subanalysis by age showed 404 patients under 20 years (NE, 26,207 [20%]), 630 patients aged between 20 and 39 years (NE, 44,024 [48%]), 281 patients aged between 40 and 59 years (NE, 18,134 [20%]), and 35 patients aged 60 years or older (NE, 2,326 [3%]) (Table 1).

Table 1.

Demographic Data

Patient Characteristic	Study Participants	National Estimate
Age at diagnosis, mean ± standard deviation (range), yr	29.2 ± 13.8 (3-81)	29.2 ± 13.6 (3-81)
Sex, n (%)
Male	1,088 (80.1)	73,760 (81.2)
Female	271 (19.9)	17,112 (18.8)
Total	1,359	90,872

The most commonly injured body parts were the face (NE, 35,155 [39%]), head (NE, 32,068 [35%]), neck (NE, 11,557 [13%]), mouth (NE, 6,666 [7%]), and ear (NE, 4,331 [5%]). The most common diagnoses were laceration (NE, 48,258 [53%]), internal injury (NE, 10,059 [11%]), strain/sprain (NE, 8,371 [9%]), contusion/abrasion (NE, 7,926 [9%]), fracture (NE, 5,741 [6%]), and concussion (NE, 4,918 [5%]). Concussions, which comprised 8% of HN injuries in the age group younger than 20 years, were more common in the age group younger than 20 years than in the other age groups (Fig 1).

Fig 1.

Age breakdown of most common injury diagnoses.

The most common overall mechanisms of injury were impact with board (NE, 48,360 [53%]), impact with ocean floor (NE, 8,690 [10%]), fin-associated injury (NE, 3,610 [4%]), impact with other surfer (NE, 2,157 [2%]), and not specified (NE, 25,906 [29%]). The most common mechanisms of internal head injuries were impact with board (NE, 6,275 [44%]), not specified (NE, 4,108 [29%]), impact with ocean floor (NE, 2,408 [17%]), impact with other surfer (NE, 621 [4%]), and impact with water (NE, 404 [3%]) (Fig 2).

Fig 2.

Mechanisms of concussion national estimates and overall national estimates. (HN, head and neck.)

There were statistically significant decreases in overall ED-managed injuries with all included data (P < .01) (coefficient, –270; 95% confidence interval [CI], –335 to –206]) (Fig 3). Additionally, there were significant decreases in impact-with-board injuries (P < .01) (coefficient, –177; 95% CI, –237 to –117). Similar analyses of all internal head injuries and internal head injuries with loss of consciousness did not yield statistically significant results. There were decreases in the following diagnoses: laceration (P < .01) (coefficient, –208; 95% CI, –258 to –158), fracture (P = .02) (coefficient, –19; 95% CI, –35 to –3), strain/sprain (P = .03) (coefficient, –21; 95% CI, –40 to –2), and contusion/abrasion (P = .03) (coefficient, –23; 95% CI, –43 to –2) (Fig 4). To account for potential effects of the COVID-19 pandemic, the same analyses were performed with all data except those from 2020. There were no notable differences between the primary analysis and the pandemic subanalysis.

Fig 3.

Annual national estimates of surfing head and neck (HN) injuries from 2003 to 2022.

Fig 4.

Most common diagnoses and concussion annual national estimates.

Discussion

This study found a decrease in surfing HN injuries presenting to EDs, although there was no significant change in concussion-related or internal head injury–related ED presentations. Prior studies have shown similar decreases in surfing injuries presenting to EDs affecting other parts of the body, but research focusing on surfing HN injuries and injury mechanisms is scarce.¹ As surfing continues to grow in popularity, concussion awareness and management become more paramount.

Among surfing HN injuries, lacerations were the most common diagnosis and impact with board was the most common mechanism. Both findings align with previous literature examining mechanisms of surf injuries affecting other body parts.^1,12,17,21 These findings are not surprising given that many of the mechanisms of surf injuries involve an impact between the surfer and another object. Any part of a surfer’s body may be exposed to these impacts, especially considering that the nature of “wiping out” often results in rapid changes in body positioning.

The decrease in surfing HN injuries presenting to EDs found in this study also aligns with prior literature pertaining to surfing injuries affecting other body parts.^1,2 Several hypotheses regarding alternative management and injury prevention have been proposed to explain this. With respect to alternative management, the literature has suggested that increased urgent care use and increased onsite management by lifeguards and other surfers may have contributed to decreasing surfing-related ED presentations.^1,2 Moreover, surfers may self-treat their injuries to avoid ED visits. Next, the use of soft-top surfboards and protective headgear has been hypothesized to aid in preventing surfing injuries.^1,22 However, targeted studies have not been conducted, and the NEISS database does not provide enough detail to confirm any of these hypotheses.

As the rate of surfing HN injuries presenting to EDs decreased, there was no change in the rate of surfing-related concussions presenting to EDs. Concussions represented 5% of all surfing HN injuries presenting to EDs. The proportion of all surf injuries that are concussions varies significantly within the literature, ranging from 2.7% to 34%.^13,23 An online survey of 50 surfers in 2015 found that 70% of respondents reported head injuries, and 37% of these were concussions.²⁴ Although nearly 40% of surfers recognize the risk of concussion or head injury as moderate to high, many surfers believe that wearing protective headgear is generally uncomfortable, is visually unappealing, or reduces their sense of proprioception.²⁵ As such, fewer than 10% of surfers actually wear headgear.¹⁶ This study found that rates of concussion were highest among the age group younger than 20 years, aligning with findings from Hager et al.¹⁴ This result highlights the need for increased focus on concussion prevention and screening within the pediatric population.

Compared with common injuries such as lacerations, concussions may be considered more severe. Therefore, alternative treatment strategies such as urgent care use, onsite management, or self-treatment may be less viable, and ED visits may be required. Another potential factor contributing to the lack of decreasing concussions presenting to EDs is a widespread increase in concussion awareness and protocols within other sports. For example, in 2009, both the National Football League and the National Federation of High School Sports adopted guidelines for concussion management, and the National Collegiate Athletic Association followed in 2010.26, 27, 28, 29 Concussion protocol implementation continued to increase significantly throughout the 2010s.^26,29 Surfers may have learned about concussion management as awareness grew within other sports, and thus, surfers may have been more likely to seek treatment for surf-related concussions as time progressed. On the other hand, most surfing occurs recreationally, and participation thereby lacks rules, regulations, or strategies for injury prevention and treatment.

Although concussion awareness has improved in many other sports, the topic of surfing-related concussions has not been extensively studied. Notably, the World Surf League, which consists of athletes at the highest level of competitive surfing, did not implement a concussion protocol until 2022.³⁰ Additionally, several cases in which professional surfers experienced severe brain injuries have been covered by surf media.31, 32, 33 Because of a historic lack of emphasis, concussions within surfing have likely been underdiagnosed for decades, and they may continue to be underdiagnosed until awareness and management protocols are improved. One challenge in detecting surf-related concussions is that an abnormal impact may not be required to cause a concussion. For example, common actions such as falling off the surfboard or “duck diving,” a maneuver in which the surfer submerges the surfboard and his or her body to pass underneath oncoming waves while paddling out, are often harmless. However, in some cases, surfers may experience impacts with the ocean surface or with the waves that may injure the brain. It has also been shown that small, repetitive impacts can have severe long-term consequences, such as chronic traumatic encephalopathy, as seen in linemen in football.³⁴ Without definitively abnormal trauma such as an impact with a board or impact with the reef, a surfer may be less likely to undergo evaluation for a concussion. Another unique challenge related to concussion screening and management is that the vast majority of surfers engage in the sport recreationally, and thus, there is no supervising entity to enforce concussion-related protocols.

Improved concussion detection and management within surfing are paramount to prevent severe complications such as second impact syndrome, complex neuropsychiatric disorder, and chronic traumatic encephalopathy, which may be severely debilitating or fatal.^35,36 Future studies involving longitudinal measurement and including details such as concussion history, long-term sequelae, geographic location, ocean conditions, surfer skill level, and equipment may offer greater insight into the risk factors and preventative measures for surfing-related HN injuries.

Limitations

There are several limitations to this study, many of which are due to the use of a large national database. First, the classification of each injury mechanism was dependent on the specificity of information provided in the narrative. There was a large proportion of records in which the injury mechanisms were not specified (29%). Next, because of the geographic constraints inherent to the sport of surfing, the true incidence of surfing injuries may not be reflected by the 100 hospitals included in the NEISS database.³⁷ The geographic locations of each ED were not provided for each data point, so it was not possible to use the ED location to check for wave pool–associated injuries that may have been missed through our exclusion strategy. Regardless, it is possible that patients with ocean surfing injuries may present to EDs anywhere in the United States given that surfers may seek medical care in landlocked regions after returning from surf trips. Furthermore, the NEISS database only includes ED visits and thus is unable to capture surfing injuries managed at urgent care centers, onsite at the beach, or through self-treatment. Finally, there are many factors associated with surf injury risk that could not be evaluated because of the limited narrative detail available. For instance, wave type, geographic location, sea floor and depth, surfer skill level, and equipment (e.g., surfboard type, wetsuit, and helmet) may play a significant role in surfing injury risk, but the NEISS database lacked detail to capture such data.

Conclusions

Although surfing HN injury ED presentations decreased from 2003 to 2022, the rate of surfing-related concussions presenting to EDs remained steady. Concussions therefore remain a significant concern in surfing, especially among surfers under 20 years of age.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: S.K.Y.C. has received research support from Smith & Nephew. C.S.A. has received royalties, nonconsulting fees, and consulting fees from Arthrex. C.A.P. has received education payments from Arthrex and Gotham Surgical Solutions & Devices. D.P.T. has received education payments from Arthrex, Gotham Surgical Solutions & Devices, Peerless Surgical, and Smith & Nephew. All other authors (E.M.S., E.A.R., K.K.O.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.