INTRODUCTION

Surfing is a sport originating in Hawaii, with roots extending back over 1,000 years and early records of individuals using primitive surfboards^1,2. Today, it is a widely practiced recreational activity enjoyed by people across diverse socioeconomic backgrounds, age groups, geographic locations, and genders^3,4. While some individuals surf recreationally, for others, it constitutes an integral aspect of daily life in coastal communities⁵. The main components of surfing involve paddling, wave riding, jumping, and performing acrobatic maneuver^4,6,7.

The practice of surfing entails a substantial risk of head and facial injuries, with approximately half of all surfing-related emergency admissions attributed to such injuries⁸. Estimates suggest that one in three surfers sustains injuries severe enough to require a hiatus from the sport⁵. Recreational surfers experience an injury rate of approximately 1.23 to 3.5 injuries per 1,000 hours of surfing^9,10, whereas professional surfers report an increased rate of 6.6 injuries per 1,000 hours¹¹. Additionally, accidents may include marine wildlife attacks¹².

Data from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission reported that between 2002 and 2013, approximately 131,494 injuries were documented among 2,072 surfers¹³. Common injuries in the head and facial regions among surfers include lacerations, soft tissue contusions, facial fractures, eye trauma, and dental fractures^4,14-17. Further studies have identified injuries in the lower back, foot, knee, and ankle regions¹⁸. In Australia, the National Media and Incident Reporting and Forensic Information System recorded 155 surf- and bodyboard-related fatalities between June 2004 and June 2020¹⁹.

It is estimated that contusions and facial lacerations affect between 29% and 42% of surfers across various geographical areas^5,9,20. These injuries necessitate rest periods to allow for recovery⁵. A minor risk of concussion has also been documented in surfing accidents, with incidence rates between 3.2% and 6.5%. Knowledge of the injury patterns and mechanisms among surfers has informed the development of safety accessories and surfboard designs that aim to reduce accident risk⁸.

Several factors are associated with increased injury risk in surfing, including competitive surfing^9,10, experience level⁸, training frequency of at least three times per week^8,22), wave size^11,23, rocky or reef bottoms¹³, and age²⁰. Although no significant differences in injury rates have been observed by gender, males have been documented to experience higher injury rates, partially due to their higher participation rates in surfing^5,8-10,23. Additionally, surf instructors and competitive surfers are noted to be susceptible to orthopedic, skin, and external injuries^24,25.

Understanding the distribution and types of injuries in surfing is critical, as they impact both the physical and emotional well-being of participants¹⁶. Currently, no studies in our region address the frequency of surfing injuries, and estimates of the number of individuals affected are lacking. The objective of this research was to estimate the frequency of head, face and neck injuries and identify associated factors in recreational surfers in Acapulco, Mexico

MATERIAL AND METHODS

RESULTS

In the total sample, four surfers were excluded, resulting in a final analysis based on 125 participants. 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), characterized by a sandy bottom type (n=108; 86.4%) and a wave length of two meters (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).

DISCUSSION

Approximately 37.6% of recreational surfers in Acapulco, Mexico, reported experiencing at least one head, face, or neck injury within the past year. Most injuries were superficial scrapes, primarily resulting from impacts with the surfboard, and did not prevent continued surfing. Three risk factors were identified: ≤10 years of practice, wave heights ≥2 meters, and the absence of a board leash.

The frequency of reported injuries was moderate and comparable to rates found in Portuguese surfers⁹, contrasting with the higher injury occurrence reported in Brazilian and Australian surfers^17,18. It is important to note that the injury distribution was episodic; however, when examining lifetime injuries across all body regions, the injury rate increased significantly. 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, in a systematic review, 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.