Introduction
Surfing is a sport with origins in Hawaii dating back more than 1,000 years, with reports of people using primitive surfboards.
1
2
It is a recreational sport enjoyed by people of a variety of socioeconomic backgrounds, ages, geographic locations, and sex.
3
4
Some persons surf for recreation, but others consider it a fundamental part of the daily routine in coastal communities.
5
The main parts of the activity of surfing involve paddling, jumping, riding waves and performing acrobatics
4
6
7
The practice of surfing carries a significant risk of head and facial injuries, with nearly half of all surfers admitted to emergency services for these reasons.
8
It is estimated that one in three surfers experience an injury serious enough to keep them out of the water for varying periods of time.
5
Injuries in recreational surfers average around 1.23 to 3.5 per 1000 hours of practice
9
10
, and 6.6 per 1000 hours in professional surfers
11
. Other accidents also include attacks by marine wildlife
12
The National Electronic Injury Surveillance System of the US Safety Commission database mentions that at the year 2002 to 2013, approximately 131,494 injuries were recorded on 2,072 surfers.
13
Common injuries sustained by surfers to the head and facial region include lacerations, tissue contusions, facial fractures, eye trauma and dental fractures.
4
14-
17
Further studies report lesions in the lower back, foot, knee, and ankle regions.
18
In Australia, the National Media and Incident Reporting and Forensic Information System adjudicated 155 surf and bodyboard fatalities during the period June 2004 to June 2020.
19
It is estimated that contusions and facial lacerations affect 29% to 42% of surfers in different geographical regions.
5
9
20
These types of injuries require rest periods that allow surfers to recover.
5
Even a minimal risk of concussion has been documented in this type of accident, ranging from 3.2% to 6.5%. Knowledge of the spectrum and mechanisms of injuries suffered by surfers drives the design of accessories and boards that minimize the risk of accidents.
8
Concerning the factors associated with surfing, it is documented that competitive surfers are more at risk than recreational surfers.
9
10
Experience in surfing,
8
training at least three times a week,
8
22
wave size,
11
23
surfing on rocky or reef bottom,
13
and age.
20
In terms of sex, no evidence has been found, but males are described as having the highest number of injuries, partly due to the fact that they are more likely to surf.
5
8-
10
23
It is even mentioned that surf teachers and competitive surfers are susceptible to orthopedic, skin and external injuries during their practice.
24
25
It is important to know the distribution of injuries in surfers, since they will always influence both the physical and emotional aspects of those who practice it.
16
In our region, there are no studies that denote the frequency of the event, so an estimate of persons who practice it and who have a history of accidents is unknown. The objective of the research was to generate knowledge on the subject in order to estimate the frequency of injuries in the head, face, and neck region and the associated factors in recreational surfers in Acapulco, Guerrero, Mexico.
Material and Methods
Study design
Cross-sectional study that estimated the frequency of head, face and neck injuries and identified associated factors in recreational surfing in Acapulco, Guerrero, Mexico during the period of January to August 2023. Acapulco, located on Mexico's Pacific coast, is known for its favorable surfing conditions, attracting both local and international surfers year-round. With a range of beaches that cater to varying skill levels, Acapulco is a prominent destination for recreational surfing within the region, which provides a relevant context and justification for selecting this location as the study area.
Population and sample
Based on a non-probability snowball sampling, six surfers were identified and assisted in disseminating the measurement instrument, with a scope of 129 recreational surfers included. The inclusion criteria were people of legal age who practice recreational surfing in the different beaches of Acapulco. To reduce selection bias, four people belonging to a professional surfing committee with a history of participation in national and international competitions were excluded, as well as people with a physical limitation that kept them out of the practice. As for elimination criteria, only incomplete forms were eliminated.
Instrument and variables
The measurement instrument was a 44-item form validated with experts in the areas of Epidemiology, Public Health, Anthropology, Maxillofacial Surgery and one expert in the subject of surfing
26
. Sociodemographic data was collected on surfing, surfboard parts and accessories (Table 1), considerations on the practice and mainly physical injury related aspects. The outcome variable was the history of any injury to the head, face and neck region in the last year according to the established nominal categories (yes/no). Some explanatory variables were estimated with information collected, such as body mass index (BMI), which was categorized based on the parameters established in national guidelines: grade 1: BMI 30-34.9; grade 2: BMI 35-39.9; and grade 3 BMI > 40
27
. The rest of the variables were operationalised according to the researchers' criteria based on scientific evidence.
Procedures
The measurement instrument was developed via a Microsoft Forms® form, and the link generated was shared with the first recruiters, who shared it with their acquaintances. The replies were compiled into a database in an Excel template and coded for analysis
28
.
Statistical analysis
Statistical analysis of the data was processed with the CIETmap package.
29
A descriptive analysis was performed for simple frequencies of each of the study variables; subsequently, the Mantel-Haenszel process was used to estimate the odds ratio (OR) along its confidence interval of 95% (CI95%) in the bivariate and multivariate analyses. The multivariate analysis began with the saturated model, where the explanatory variables that reached statistical significance were included and eliminated one by one with the backward method, until those with a level of significance in the final model were left (P < 0.05).
Ethical aspects
The research protocol was approved by the Research Ethics Committee of the State Health Services of Guerrero, Mexico with the folio number 10281022, and was considered risk-free accordance to the guidelines established in the Regulations of the General Health Law on Research. The study adhered to the ethical principles outlined in the Declaration of Helsinki. The form was applied online using Microsoft Forms® and was answered freely and voluntarily with an informed consent checkbox. The application complied with the General Data Protection Regulation, given that it did not request the linking of e-mail, which guaranteed the anonymity of the participants.
Results
Among the total population, four surfers were excluded, so the analysis considered 125 observations. Age ranged of 19 to 41 with a mean of 26.9 years (SD= 4.6). Regarding anthropometric measurements, weight ranged of 38 to 95 with a mean of 65.5 kilograms (SD=10.1); and height ranged of 1.54 to 1.86 with a mean of 1.71 meters (SD= 0.06). When estimating BMI, values ranged of 15.6 to 34.9 with a mean of 22.2 (SD=2.7). The sociodemographic characteristics of the surfers are shown in Table 2.
In relation to the information on surfing, only 12% (n=15) of the people mentioned physiotherapy activities as a complement to the practice of the sport. The majority learned surfing self-taught (n=77; 61.6%), with ≤ 10 years of experience (n=106; 84.8%), practice days per week ≥ 2 days (n=84; 67.2%) and ≤ 10 hours practice hours per week (n=108; 86.4%). Bonfil beach is the most visited with 68.1% (n=85), characterised by a sandy bottom type (n=108; 86.4%) and a wave length of two metres (n=63; 50.4%).
On the board, the most used is the pointed nose (n=86; 68.8%), the continuous rocker (n=75; 60.1%), the rounded tail (n=54; 43.2%), the polyester resin board (n=96; 76.8%) with rounded rails (n=69; 55.2%). Concerning the fins of the board, most of them have three fins (n=62; 49.6%), with leash (n=87; 69.6%) and use of grip (n=77; 61.6%).
Regarding some perceptions of situations prior to surfing, 44.8% (n=56) considered warm-up exercises, wind conditions (n=54; 43.2%), swell conditions (n=58; 46.4%), keel position (n=69; 55.2%) and board waxing (n=75; 60.1%) to be of high importance. The 16% (n=20) use a face-shield, the 63.2% (n=79) usual route is position to take the wave face on (frontside), and the 66.4% (n=83) surf with the right foot placed in the rear position on the board (regular). Some 6.4% (n=8) produce teeth clenching and 1.6% (n=2) wear protective eyewear during their rides. Table 3 describes the information on the characteristics of surfing.
The 93.6% (n=117) of surfers have experienced a lifetime bodily injury while surfing. In the last year, 37.6% (n=47) of surfers have experienced at least one injury to the head, face and neck region, with a frequency of 1 to 3 times (mean 1.13; SD=3.6). The highest proportion of injuries were superficial scrapes (51.1%; n=24/47), followed by contusion (31.8%; n=15/47) and lacerations (17.1%; n=8/47). With respect to the type of accident, striking the surfboard was the most frequent with 82.9% (n=39/47), and the rest of the impacts with the seabed. None of the injuries caused any situation limiting practice or dental loss.
In the bivariate analysis there were five factors potentially associated with head, face and neck injuries in recreational surfers: years in practice, wave size, use of the board leash, consideration of keel position and waxing of the surfboard prior to surfing (Table 4). Only three variables were associated with injuries with independent effect in the final multivariate model: years in practice, wave size and not use of the of the board leash (Table 5).
Table 1
Description of surfboard parts and accessories.
| Surfboard parts and accessories |
Description |
| Nose |
Part of the board that has a relevant influence on paddling and manoeuvrability. |
| Rocker |
It is the curvature of the surfboard from the tip to the tail. |
| Tail |
Part of the board that has a relevant influence on speed and manoeuvrability. |
| Stringer |
Part that helps to resist and absorb the typical impacts that occur during surfing. |
| Rails |
These are the edges of the board that extend over the tail, through the sides, to the nose. |
| Keels |
Device that gives stability, control, and direction to the surfboard. |
| Leash |
Safety element that always keeps the surfer on the surfboard. |
| Grip |
Accessory that attaches to the board made of foam or cork, and helps to improve stability and adherence on the water. |
| Board waxing |
Surf wax keeps the surfer connected to the board in order to prevent slipping and improve wave performance. |
Table 2
Sociodemographic characteristics in surfers of the Acapulco region
| Factor |
Category |
Frequency |
% |
| Sex |
Male |
111 |
88.8 |
| Female |
14 |
11.2 |
| Age |
≤ 25 years |
47 |
37.6 |
| ≥ 26 years |
78 |
62.4 |
| BMI |
Normal weight |
100 |
80.0 |
| Low weight |
12 |
9.6 |
| Overweight |
12 |
9.6 |
| Obesity |
1 |
0.8 |
| Education level |
Undergraduate |
87 |
69.6 |
| High school |
32 |
25.8 |
| Middle school |
6 |
4.6 |
| Social security |
Yes |
25 |
20.1 |
| No |
100 |
79.9 |
Table 3
Surfing characteristics of recreational surfers in the Acapulco region
| Factor |
Category |
Frequency |
% |
| Experience years |
≤ 10 years |
106 |
84.8 |
| ≥ 11 years |
19 |
15.2 |
| Practice days per week |
1 |
41 |
32.8 |
| ≥ 2 |
84 |
67.2 |
| Practice hours per week |
≤ 10 |
108 |
86.4 |
| ≥ 11 |
17 |
13.6 |
| Frequent beach |
Bonfil beach |
85 |
68.1 |
| Pie de la Cuesta beach |
40 |
31.9 |
| Type of seabed |
Sandy |
108 |
86.4 |
| Rocky |
17 |
13.6 |
| Wave size |
1.5 meters |
22 |
17.6 |
| 2 meters |
63 |
50.4 |
| 2.5 meters |
40 |
32.0 |
| Type of nose |
Pointed |
86 |
68.8 |
| Rounded |
36 |
31.2 |
| Type of rocker |
Continued |
75 |
60.1 |
| Phased |
34 |
27.2 |
| Hybrid |
16 |
8.7 |
| Type of tail |
Rounded or squash |
54 |
43.2 |
| Diamond tail |
39 |
31.2 |
| Swallowtail |
32 |
25.6 |
| Type of stringer |
Polyester resin |
96 |
76.8 |
| Carbon fiber |
18 |
14.4 |
| Fiberglass |
11 |
8.8 |
| Type of rails |
Boxy rails |
69 |
55.2 |
| Hard rails |
56 |
44.8 |
| Number of keels |
1 |
37 |
29.6 |
| 2 |
27 |
21.6 |
| 3 |
61 |
48.8 |
| Warm-up exercises |
High importance |
56 |
44.8 |
| Medium importance |
47 |
37.6 |
| Low importance |
22 |
17.6 |
| Wind conditions |
High importance |
54 |
43.2 |
| Medium importance |
45 |
36.0 |
| Low importance |
26 |
20.8 |
| Swell conditions |
High importance |
58 |
46.4 |
| Medium importance |
43 |
34.4 |
| Low importance |
24 |
19.2 |
| Keel position |
High importance |
69 |
55.2 |
| Medium importance |
15 |
12.1 |
| Low importance |
41 |
32.7 |
| Board waxing |
High importance |
75 |
60.1 |
| Medium importance |
16 |
12.7 |
| Low importance |
34 |
27.2 |
| Usual route along surf |
Frontside |
79 |
63.2 |
| Backside |
46 |
36.8 |
| Position of the foot on the board along surf |
Regular |
83 |
66.4 |
| Goofy |
42 |
33.6 |
Table 4
Bivariate analysis of factors associated with head, face, and neck injuries in recreational surfers in the Acapulco region
| Factor |
Category |
Injury (n=47) |
No Injury (n=78) |
uOR |
CI 95% |
| Sex |
Female ref |
5 |
9 |
0.91 |
0.29 - 2.92 |
| Male |
42 |
69 |
|
|
| Age |
≤ 25 years ref |
13 |
34 |
0.49 |
0.23 - 1.08 |
| ≥ 26 years |
34 |
44 |
|
|
| BMI |
Uneven weight ref |
6 |
19 |
0.45 |
0.17 - 1.22 |
| Normal weight |
41 |
59 |
|
|
| Education level |
High / middle school ref |
12 |
26 |
0.69 |
0.31 - 1.54 |
| Undergraduate |
35 |
52 |
|
|
| Social security |
No ref |
36 |
64 |
0.72 |
0.29 - 1.74 |
| Yes |
11 |
14 |
|
|
| Surfing learning mode |
Self-taught ref |
25 |
52 |
0.57 |
0.27 - 1.19 |
| Influence by others |
22 |
26 |
|
|
| Experience years |
≤ 10 years ref |
36 |
70 |
0.37 |
0.14 - 0.97* |
| ≥ 11 years |
11 |
8 |
|
|
| Practice days per week |
1 ref |
13 |
28 |
0.68 |
0.31 - 1.50 |
| ≥ 2 |
34 |
50 |
|
|
| Practice hours per week |
≤ 10 hours ref |
41 |
67 |
1.12 |
0.38 - 3.28 |
| ≥ 11 hours |
6 |
11 |
|
|
| Frequent beach |
Bonfil beach ref |
31 |
54 |
0.86 |
0.40 - 1.87 |
| Pie de la Cuesta beach |
16 |
24 |
|
|
| Type of seabed |
Rocky ref |
9 |
8 |
2.07 |
0.75 - 5.75 |
| Sandy |
38 |
70 |
|
|
| Wave size |
≥ 2 meters ref |
34 |
69 |
0.34 |
0.14 - 0.86* |
| < 2 meters |
13 |
9 |
|
|
| Type of nose |
Pointed ref |
36 |
50 |
1.83 |
0.81 - 4.15 |
| Rounded |
11 |
28 |
|
|
| Type of rocker |
Hybrid / Phased ref |
14 |
36 |
0.49 |
0.23 - 1.06 |
| Continued |
33 |
42 |
|
|
| Type of tail |
Squash ref |
21 |
33 |
1.10 |
0.53 - 2.29 |
| Swallowtail / diamond tail |
26 |
45 |
|
|
| Type of stringer |
Polyester resin ref |
32 |
64 |
0.47 |
0.20 - 1.08 |
| Carbon fiber / Fiberglass |
15 |
14 |
|
|
| Type of rail |
Boxy rails ref |
25 |
44 |
0.88 |
0.42 - 1.82 |
| Hard rails |
22 |
34 |
|
|
| Number of keels |
One ref |
17 |
20 |
1.64 |
0.75 - 3.59 |
| Two / Three |
30 |
58 |
|
|
| Leash |
Not use ref |
21 |
17 |
2.90 |
1.33 - 6.30* |
| Use |
26 |
61 |
|
|
| Grip |
Not use ref |
23 |
25 |
2.03 |
0.97 - 4.27 |
| Use |
24 |
53 |
|
|
| Warm-up exercises |
Medium / low importance ref |
24 |
45 |
0.77 |
0.37 - 1.59 |
| High importance |
23 |
33 |
|
|
| Wind conditions |
Medium / low importance ref |
30 |
41 |
1.59 |
0.76 - 3.35 |
| High importance |
17 |
37 |
|
|
| Swell conditions |
Medium / low importance ref |
24 |
43 |
0.85 |
0.41 - 1.76 |
| High importance |
23 |
35 |
|
|
| Keel position |
Medium / low importance ref |
28 |
28 |
2.63 |
1.26 - 5.51* |
| High importance |
19 |
50 |
|
|
| Board waxing |
Medium / low importance ref |
25 |
25 |
2.41 |
1.15 - 5.05* |
| High importance |
22 |
53 |
|
|
| Usual route along surf |
Frontside ref |
32 |
47 |
1.41 |
0.66 - 3.02 |
| Backside |
15 |
31 |
|
|
| Position of the foot on the board along surf |
Regular ref |
34 |
49 |
1.54 |
0.70 - 4.40 |
| Goofy |
13 |
29 |
|
|
| Teeth clenching along route |
Noref |
42 |
75 |
0.34 |
0.08 - 1.40 |
| Yes |
5 |
3 |
|
|
| Use of face shield along route |
Not use ref |
37 |
68 |
0.54 |
0.21 - 1.42 |
| Use |
10 |
10 |
|
|
Ref= Reference category.
uOR= Unadjusted odds ratio.
CI95%= Confidence interval of 95%
Table 5
Final model of the multivariate analysis of the factors associated with head, face, and neck injuries in recreational surfers in the Acapulco region
| Factor |
Category |
uOR |
aOR |
CI 95% |
X² het |
P |
| Experience years |
≤ 10 years |
0.37 |
0.32 |
0.11 – 0.94 |
4.11 |
0.995 |
| Wave size |
≥ 2 meters |
0.34 |
0.27 |
0.09 – 0.82 |
5.30 |
0.993 |
| Leash |
Not use |
2.90 |
3.64 |
1.70 – 8.94 |
10.35 |
0.985 |
uOR= Unadjusted odds ratio.
aOR= Adjusted odds ratio.
CI95%= Confidence interval of 95%.
X2 het= Chi-square of heterogeneity to identify effect distractor.
P= Significance level for heterogeneity test.
Discussion
The 37.6% of recreational surfers in Acapulco, Mexico have experienced at least one injury to the head, face and neck region in the last year. The majority of the injuries were superficial scrapes as a result of blows with the board, none of which made it impossible to continue surfing. Three factors were associated: practice ≤ 10 years, wave size ≥ 2 meters, and not use of the board leash.
The frequency of injuries reported was moderate, similar to that obtained in Portuguese surfers
9
; in contrast to Brazilian and Australian surfers, who report a higher occurrence
17
18
. It is important to mention that the reported distribution was lapsical, so that when we delve deeper into lifetime injuries in any body region, the rate increased. Monteiro et al
25
. reported that injury prevalence in recreational surfers ranges of 31% to 35%, rising to 42% to 49% in competitive surfers, with lifetime injury rates across both groups spanning from 81% to 100%. In a separate study, the incidence of injuries among New Zealand surfers was estimated at 27%
22
.
Regarding experience, a shorter surfing history was associated with a reduced risk of injury, which contradicts findings by Minghelli et al
9
. and Cordeiro et al
17
, who suggest that inexperience is linked to a higher injury risk. This discrepancy may be influenced by other factors impacting experience, such as the frequency and duration of weekly surfing sessions; in this study, 67.2% of participants surfed at least twice weekly, yet 86.4% reported spending 10 hours or less surfing each week. Therefore, if this assumption holds, fewer years of practice may correlate with shorter cumulative exposure to injury. Lawes et al
19
. documented that Australian surfers engage in surfing an average of 45.7 times annually, for 1.88 hours per session, totaling 86.1 hours of exposure, which could even influence sport-related mortality rates.
Concerning wave size, Nathanson et al
11
indicated that healthcare professionals attribute larger wave heights to an increased risk of surfing injuries. In contrast, our findings suggest an inverse relationship, where larger waves correlate with a reduced injury likelihood, aligning with Thom et al
23
, who found that waves under 1.25 meters increase the accident probability by 40% among Australian surfers. This variability may largely depend on the coastal geography, wave sizes specific to the region, and the type of seabed. We postulate that larger waves might decrease the chance of impact with the seabed or other structures, affording surfers more time to maneuver and reduce injury risk.
With respect to surfboard accessories, our study identified the lack of a leash as a significant injury risk factor. The leash assists in retaining board contact after falls or capsizes, serving as a buoyancy aid and enhancing safety for the surfer and others. MacArthur et al
15
emphasized that protective equipment, including leashes, reduces injury rates among surfers. Therefore, we infer that inadequate use of protective equipment could precede injuries.
Regarding injury types, most were superficial abrasions from board impacts, similar to reports in other studies
5
,
8
,
15
. In contrast, severe injuries requiring emergency care and extended recovery periods have been reported in other research
8
,
10
,
13
,
20
. Remmant et al
22
documented that of 550 serious injuries, 44% had a recovery period of under three months, while 56% required longer.
This study appears to be among the first to examine surfing-related injuries in Mexico, particularly in Acapulco, Guerrero, underscoring the importance of healthcare access. Currently, government-provided emergency medical services for surfers are limited, as public health services prioritize conditions associated with population-level morbidity and mortality. Consequently, surfing injuries are not recognized as a public health priority, even by organizations such as the World Health Organization
30
. Nonetheless, this study highlights the injury risks faced by surfers and the need for affordable healthcare services, especially in the public sector.
Due to the cross-sectional design, establishing causal relationships is limited, as the modifiable factors could precede or follow the reported injury, introducing potential inverse causality. The retrospective nature of data collection further limits precise reconstruction of events, highlighting the need for longitudinal studies to better explore temporality. Additionally, body mass index (BMI) was calculated based on self-reported weight and height, which may introduce reporting bias. Specific anatomical details of injury locations were not collected, being instead described regionally; future studies should incorporate an anatomical map for respondents to indicate high-risk areas.
The snowball sample selected for the study is not representative of recreational surfers in the region, as it lacked a formal sample size calculation, and the initial recruiters were able to designate individuals with similar traits and characteristics. This limited the diversity within the sample and made it impossible to extrapolate the results. Non-differential selection bias is evident, caused by overlapping connections among the initial recruiters and the interconnectedness of links with the other participants. Nevertheless, the chain process benefited in reaching out to this type of population and for future research to get an estimate of the number of surfers on the different coasts of the state.
Conclusion
Injuries to the head, face, and neck region in recreational surfers in Acapulco are moderate, with most being superficial and primarily caused by surfboard impacts; key risk factors include less surfing experience (≤10 years), smaller waves (<2 meters), and not using a leash. The findings underscore the importance of promoting safety measures such as the use of leashes on the board, even among more experienced surfers, to decrease the risk of injury in this sport. Future research with representative sampling methods could validate and extend these results by providing a more complete understanding of the factors influencing surfer safety.
Acknowledgments
We thank Alam García “Chaneque” a surfer in Bucerias, Nayarit for his support in the thematic for the proposal of the instrument. We thank the renowned surfers in Acapulco who were the initial recruiters and supported the dissemination of the instrument, Gustavo Adolfo Cortes Alvarado, José Ángel Jacinto Ayvar “Chispa”, Dhafne Larissa Salinas Abarca, Javier García Poblete, Alan Valdes “Chango” and Mario Llorens Wallace.
