Health Issues for Surfers ?
TODD B. ZOLTAN, M.D., J.D., Los Angela Free Clinic, Los Angefw, California
KENNETH S . TAYLOR, M.D.,
and SURAJ A. ACHAR, M.D.,
University o f Califomin. Son Diego, School ofMedicire, L z ]loll@, California
Surfers are prone to acute injuries as w e l l as conditions resulting fiom duo& e n m e n t a l exposure. Sprains, lac-
erations, strains, and fra-
are the most common types o f trauma. Iajury f r o m the rider's own surfboard may be
the prevsfig mechanism. Mhor wound infections can be treated on an outpatient basis with dpmfhwh or trim-
ethoprim-sulhmethommle. Jey.fish stings are common and may be treated with heat application. Other treatment
regimens have bad mixed d k
Seabather's eruption is a pruritic skin feaction c a d by expiwe to nematocyst-
wnhbing dentmate larvae. Additional s~
include stingrays, coral K&
logic quelae o f &g
include auditory aost-
tympanic ~ b r a n e
and skin ancer risk are inherent dangers o f this spwt. (Am Fam Physician 2005;71:2313-7,23 19-20. Copyright@ 2005
Amerian hdemy of Family P h y s i b )
and, ocmsionally, &arks. Oto-
rupture, and otitis exkrna. Sun exposure
A handout on safe d n g ,
written by the authors of
thls artlcle, k provided on
See page 2237 for
illions of surfers worldwide are
prone to a unique constellation
of acute and chronic mnditions.
Family physidanar in w t a I
"areas should be
, ~isurfing injuries such as envenomations lac-
.I - d l'erations, sprains, and fractures, and to counsel
. surfers about the risks of sun exposure,
.. I ,
- . Trauma
Cho studies1v2 assessed the frequency and
2 u.d'types of surfing injuries. Sprains, disloca-
tions, strains, iacemtiws, and fractures were
found to be the most common injuries. One
study fwnd an werall rate o f 3.5 injuries
per 1,000 surfmg days. More advanced surf-
' q r s , who oftm engagrlarger waves in more
extreme conditions, were found to have more
injuries then less experienced surfers.
safetyFmeasures can help reduce the he-
Juency and severity of injuries. Most surfers
are Jgjypd from contact with their own
sufiorrd's side rails and fins '(Figure i12
Several safety devices are available, but none
has been proven to prevent surfing injuries.
Rubber guards for the board's nose and soft-
7 I TF-
edged or rubber-guarded fins may prevent
lacerations without altering the dynamia of
the surfboard. Surfing helmets may prevent
head injuriesa3 Protective eyewear designed
specifically for surfers may protect against
. uItrayioIet rays. and orbid trauma.
The use of a s w h d leash for injury
prevention is controversial. Leashes seem to
. . p a
- m D p -
reduce t l _lumber of ~idents caused by
loose boards hitting other surfers,' and they
ensurelthat surfers will have access to a flota-
tion device if they are injured seriously. How-
ever, a leash keeps the board near the surfer,
and recoil from the leash increases the risk
o f injury. Ocular trauma most often occurs
when the board's nose strikes the surfer's eye;
one study implicates leash recoil as a cause9
Leashes are, sold in various lengths. Longer
leashes may decrease recoil injury, but they
can increase the risk of injury to others.
Lacerations can become infected with
marine organisms. Common pathogens iso-
lated from seawater and marine wounds
indude Streptococcus species, Escherichia
mli, Pseudornonas aeruginosa, Mpbacterium
mafinurn, Staphylocmus aureus, Vibrio chol-
ewe, Vibrio vulnifcus, and Vibrio parahue-
Wounds should be cultured f o r
aerobic, anaerobic, and marine organisms.
Physicians should alert laboratory person-
nel that marine organisms may be present,
Figure 1. Anatomy of a surfhad.
. Strength of Recommendation
Heat is recommended to reduce the
pain associated with jellyfish stings.
w limited-quality patient-oknted wA&nce; C = consensus, disease
usual pracrlw, or case series. See page 2237 fw
~ w l i t y p a i i e n t ~ t d ~ ~
B I inmsktmt
because specialid media or additional sodium chloride
may be necessary t o identify these pathogens pr0perli.P
Minor wounds usually do not q u i ~
m e n t . Serious wounds or wounds in immunocompro-
mised patients warrant empiric antibiotic treatment?
Initial outpatient therapy is directed at VibriD species
and includes cip-
trim, Septra)? Par-
that are appropri-
ate for initial ther-
apy include cefotaxime (Claforan), ceftazidime (Fortad,
chloramphenicol (Chloromycetin), gentamicin (Gara-
mycin),and tobrarnycin (Tobrex). Lacerations should be
allowed to heal secondarily or, if necessary, by delayed
Marine H m r c k
Although clinical -tation
ment principles apply to all types of marine envqnom-
ation. First, wounds can become infected and should drl vl
be treated as discussed above Second, ,the possibility of
retained foreign bodies sbould be consid&
patients with envenomations. Depending on the mecha-
nism of injury and level o f clinical suspicion, investigation
of a retained foreign body can be done through wound
exploration or api+te
radiographs. Finally, tetanus
immunization should be given,if necessary?
m a y wry, certain treat-
+@d b q d & y 6 s h h
multipleq &n&g tenkdes with venom-fiued cells dkd
nem*gcysts. Nematocysts inject toxins s&cutanwwiy in
rapowe t o
or mechanical stimuli. h i d symp-
toms of nqnatoqq envenomtion f r o m jellyfish dng
indude burning pain, +ma,
bullae, formation, all dwhiqh can p r o p t o skin necro-
s i s (Figwe 2 ) . Wet suits may @wa% miye env~omations
by p&enting the toxin b r n mching the &in. Howem',
stiqp through wet suits 'hve been mported.
these,^^ have a main body and
edema, urticaria, a d
further t o +
tacles or ot9er repined animal pa*
sensus for the best metbod of inacthating aematocysts
and reducing pain. T h q is some evidena that immer-
sion of the affected area in hot water and the application
of heat packs are effective pain-relief rnethad~?.~
treatments teconllm"&ded bypublished and anecdoid
include applicatidrr of cold packs and in@-
tion with ethanol, vi$e&.r, urihe, baking soda, or meth-
gated spiriti. There i s insufficient evidence t o support
one treatment over nthasbccause of the variety of study
designs and jellyfish species that were used Vigoms
rubbing and irrigation with fresh water are not recom-
mended because these methods may induce additional
Further treatment should & r c s s
symptoms. Pain and dermatitis may be treated with
analgesics and antihismine. Patients with a systrmie
reaction may have ,multiple organ sys tern involvement
and presentwith a rsriety o f syniptorns (Table I)."
temic symptoms can occur five,minutes to several born
after expure. Patients with systemic symptoms should
be monitored for symptom rebound for at least six to
The box jell@& is particularly venomous (Figure 3).
Hawaii is the only area in the United States &re this type
L InfiiaI treatm.vt of envenomat ion iamlves prevenmg
release by removing any remaining ten-
There is 40 con-
local and systcmic
I $ !
h i l 5
-. r. .
Coelenterates are invertebrates and can be &-floating or .-11
sessile. Surfers more oftea encounter fiee-floating.coden-. :
teratcs such as the true jelly&,
P o r t u v man-of-war, Figud-2 Jellyfish stings.
2314 Amsriaur FamiIy Htp-um
Volume 71, Number 12 June 15,2Q05
of jellyfish is found. Antivenin for flie box jellfish should
be used if envenomation is confirmed or suspected.
Seabather's eruption occurs when a person isexposed to
the larvae of certain coeknterates. T h i s intensely pruritic
rash is thought to be a hypersensitivity reaction to the
larval toxin. It has been reported mast often in Bermuda,
the Caribbean region, and the eastern coast of the United
States.I6 It is thought that nematocysts discharge toxin
as the Iarvae get trapped in the swimsuit. Further toxin
release can occur when the bather rinses in fresh water.I7
Patients with seabather's eruption present with an
urticaria1 maculopapular rash on areas of the body that
were covered by the swimsuit. The rash may appear
while the bather is in the water or up to one and one half
days later. The rash may last for two to 28 days; most
reactions resohe within one to two weeksAa Systemic
symptoms occur most often in children and may include
fever, nausea, vomiting, and headache." Initial treatment
involves the topical application of heat or vinegar. Fur-
ther treatment is symptomatic and may indude topical
corticosteroids, oral antihistamines, and oral steroids.
Twice-daily application of 1.5 g of thiabendazole (Mint-
ezol) for two days has been reported as eff~cacious.'~ The
swimsuit should be cleaned thoroughly because larvae
can persist and re-envenomate.
r - ' l l * - *
Figure k BOX jellyfish (Cafybdea alatd Note the charac-
Wstic boxshaped bell with tentacles extending from thq
Stingrays are bottom-dwelling creatures that usually are
encountered while surfers are entering or exiting the water.
Their tail ensheathes a sharp spine that can penetrate wet
suits and water shoes. Patients who have been stung may
present with puncture wounds or lacerations, usually in
the lower extremities, and pain disproportionate to the
wound's appearance? Initial treatment with hot-water
immersion inactivates the heat-labile toxin. Retained
animal parts should be excluded by wound exploration
or radiographs. Shuffling the feet while waking through
shallow water can prevent stings, because stingrays scatter
when they are alerted to human presence.
Cod reefs are common sources of lacerations and enven-
omations. Because of the variety of plant and anima1 spe-
cies found on coral reefs, envenomation usually involver
toxins from multi-
ple sources. Patients
with coral lacera-
tions usually present
with pain, pruri-
tus, and erythema
(Figttre 4). Wounds
should be irrigated and debrided, if necessary. Acetic acid
has been recommended for treatment of stinging pain
associated with coral envenornati~n.'~
slowly because of retained foreign material, nematoqt
discharge, and microbial inoculation." Empiric antibiotic
therapy as described above i s appropriate if the wound
appears to be infected,'
Wounds may heal
Although shark attacks garner worldwide headlina, they
are rare. In 2003, there were 55 unprovoked shark attacks
Kiiditory exostoses are bony outgrowths that arise from
q e temporal bone and protrude into the ear canal,
mtoses form in response to chronic kxposure to
*ter. They usually arc asymptomatic, but
piesent with &uqtive
haring loss, tr$qqnt ear &-
tiom, and, +si@yi
bilatwalljC with multiple amtoses in a single ear>caqL,
The presence and severity of' auditory exostoscs
directly correlates with the amount of time the p t h t
spends in the watex; Cold-*
risk for developing exostoses than warm-water si1rfers3~
haw that paom who surf mdre
frequently and for more years h&e a higher lpfevalcnce
anckseverity o f auditory exostbses than kss mperiend
surfers. The consbtent.use of carplu'gs may help prevent
exostoses froin forming. Surgery is the only treatment
for mstoses, and it usualIy i s . r e s d f m patients with
severe, rsym$tomatic cam.-
. ~ d i o ? e ~ & h y ~ E q j
surfers are at higher
TODD 6. ZEILTAN, M.D., LD., is a staff physician at the h-Angeles
Free Clinic and an officer iq the Callfmia. National Guard. lqrmy
Divish. He w e k d hih Mil degree'fiom the Unlwrsi of
Illinois College .df Meditine ~ Urbana-Champaign and his &v
degree from :the U n W ~ t y
of, IllinbinCdlege of Law, Champaign.
Dr. Zot&an pornpleted a fam!ly mqdiane residency at;theUnlversity
af,Calif@?i(a, San Dio,,S&dolmof
Midne, La alolla.
KENNETH Si-TAYLO$, MID., 6 &rector of ihe primary care sports
, @ th? Bkrslty of California; Saw Dlego,
Schpd ~tT&&$de~ 'Fli r&@il
also completed a family rndidni residency and sports mediane
%is medical degrek frwn' the
School of Medicine, where he
SURAJ A. ACHAR, M.D., is assistant director of the primary
care sports ,medMne fellwshlp at the Univwslty .of W i f p m i a ,
San Diego, School of Medicine. Dr. Achar yecelwd his medl~l
degree from the St?e,UniHrsity d New York.at ~uffalo
and Biomedical Sdences. and completed ,a' famllp ~&i-
cine residency and-a Sports-medicine 'fellowship kf the UhlUedty
of California, San Diego, School d Mediine.
Address cmegmdente to toodd 8. &kart, MM,
Free Chic, 6043 Hoil&wmi Bhd, Los Angek, C4 9 [ ) 0 2 8
(e-mail: Wta^n @lafreedink&.
D., J. D, L m
Reprints are not evsrWle'4h
2316 AR141.kan Family Phpihn
m . a
Tram, *chronic exposure to moisture, and~mastoses
make rrtitis exhma~a..'c~mmon
Otitis externa usuallf isdcziused.byWter4tapthq in. thc
e x t d auditory canal. Trauma from foreign bodie'and
wave pressure also ean cnntfibste itd inf8ction: - .
Common infecting organisms indude ,& herugin&
and S . aureus. M&paticnWmn be treated empiri-
ally with topical antihactcrial drops for 4 ' ' t o men
dam although some patienu may need -treatment: for
up to &twoO w k s . ? . anfi!-h$&&$$
ammended in -@tients with persistent 'cases or if,~titis
me44.dm.i~ ~ 5 y n t - 0 r ~ ~ ~ 4 G ~ e 4 3 ~
the ear walmE AAmg&,s&&!m. . 'as
~ m ? y u s e ~
patients wth diabctesCpkv$
preparationa &gad be considpd if $ti&~te-
+ i d treatment fails. ~ w n t i w
earplugs w h i I e . s u & m g an6 the routine use of isop1;,op~1
drops?&er surfing.. .
Went a r n u ~ s ~ .
< A "
U~CS o r potass~vm~r&id~
alwhol/acetii: acid -
by a strong
force after a fall. "'htie_qW2with
nqiture may presant *ith ear pain, eonductivc,rhear-
ruptures hesil spbribn&-wly Infedtion is minmon,ao a
short course of topical &fibioric therapy is indl6aW f o r
Patientis should be counseled t o keep fore@ material,
W d i n g Water, out d'fk ear and &wid surfing until
the perforation h q k Molded+tarplugs may be,uedb to
keept+ate;' out. o ~ ~ t h e ~ e a r ~ d u r i ~ & ~ ~ e r h d & 1 ~ ~ g ~ 1 ~ ]
may ~ q u r
g e t s t b m ~ r
when a surfer is
,A . . _ verf i p , aind bloody o m m h e ~ ~
Volume 71, Numb 12 + J~tnels 2005
Earplugs or helmets may reduce the Iikelihood of tyrn-
panic membrane rupture.
One small screening studys found that surfers have
an increased incidence of basal-cell skin cancer com-
pared with a self-selected, age-matched control group.
Sunscreen use reducts squamous-cell cancer; however,
evidence for melanoma and basal-cell carcinoma is
less clear. For example, melanoma risk may be related
more closely to exposure intensity (i.e., sunburn) than
the cumulative exposure. Persons using sunScreen may
prolong sun exposure, thereby inadvertently increas-
ing intensity and, thus, melanoma risk. Physicians can
counsel patients about cancer risk and recommend using
sunscreen with ultraviolet A and ultraviolet 0 protec-
tion, avoiding the sun between 10:OO a.m. and 4:00 p.m.,
and wearing protective
counseling patients about reducing their skin cancer risk
actually leads to behavior change.
It is unclear whether
The authors Indicate they do not have any c d k t s of interest. Sources
of funding: none reported.
Figure 3 wed with permission from Gary Bell and OceanwMe Images,
Towmina, New South Wales, Australia.
1. Natham A. Haynes P, Galanis 0. Surfing injuries. Am 1 Emerg Med
2. Lowdon U. Paternan MA, Pitmen AJ. Surfboard-riding injuries. Med 1
3. Sunshine 5. Surfing injuries. Cum Sports Med Rep 2003;2:136-41.
4. Kim JW, McDonald HR, Rubsamen P E . Lutuull JK, Dmuilhet JH, Fram-
bach DA, et al. Surfing-related ocular injuries. Retina 1998;18:424-9.
5. Lawless M, Porter W, Pountney R. Simpson M. Surfboard-related ocular
injuries. Aust N Z J Ophthalmol 1986;14:55-7.
6. Auerbach PS. Marlne envenomatlons. N Engl j Med 1991;325:486-93.
7. McGoldrick J, Marx JA. Marlne envmomation~; pan 1: vertebrates. I
Ernerg Med 1991;9:497-502.
8. Yhomas CS, Scott SA, Galanis DJ, Goto RS. Box jellyfish,(Carybdea
data) in Waikiki: their infiux cyde plus the enalgeslc effect of hot and
cold packs on their stings to swimmers at the bqach: a randomlwd.
placebo-controlled, di&l uial. Hawaii Med 1 2001 ;60:100-7.
9. Nornura JT, Sato RL, Ahern RM, Snow IL, Kwvaye I T , Yamamoto LG. A
randomized paired comparison trial of cutsneous treatments for acute
jdlyfish (Carybdea alata) stings. Am J Emerg Med 200220:624-6.
10. Hartwick R, Caltanan V, WHllamson J. Olsarming the hxjellyfnh
nematoc)n inhibltlon In Chlronex fleckerl. Med I
I?. Burnett JW, Rubinsteln H, Calton G1. First aid for jdlyf-h enwnorn-
ation. South Med 1 1983;76:870-2.
12. &ton DR. h n e r P J . W~lliamson JA. Cold packs: effective toplcal anal-
gesia I n the treatment of painful stings by Phplla and other jellyfish.
Med J Aust 1989:151:625-6.
13. Otten El, Blmkalm AL. Venomous animal injuries. In: Mark JA, Hock-
berger RS, Walls RM. Adams I. A m ' s Emergency medlclne: concepts
and'ctinical practice. 5th ed. St. Louis: Mosby, 2002:799.
14. Auerbach PS. Harardous marine animals. Emerg Med Clln North Am
15. McGoldrick J, Marx JA. Marine envenwnatbm. Part 2: invwtebrates. J
Emerg Med 1992,20:71-7.
16. Frwdenthal AR, loseph PR. Seabather3 eruption. N Engl I Med
17. hmar 5. Hbdy WG. Malecki JM. Rlsk factors for wabather's eruption:
a prospect& Gohwt study. Public Health Rep 1997;112:59-62.
18. Wong DE, Meinking T I . ,
Rosen LB, Rplln 0, Hogan Dl, Burnett JW.
Seabathds eruption. Clinical, hislologic, and immunologic features
[published wrrrction appears In J Am Acad Dermatol 1994:31:41]. J
Am Acad Demtol 1994;30:399-406.
19. Burnett 1W. Seabather's eruption. Cutis 1992;50:98.
20. Perkins RA, Morgan 55. Poisoning. enwnomation. and trauma from
marine creatures. Am Fam Physician 2004;69:885-90.
21. lSAF 2003 wotldwide shark attad: summary. Accesed online Jan-
uary 24, 2005, at: h~tp:l~.fImnh.rrfl.eduHi#shark5/5tBthtIcs/
22. Kroon DF, Lawson ML, Derkay CS. Holfmann K. McCwk, I. Surfer's
ear: external auditory exostoses are more prevalent in cold w a t ~
ers. Otdaryngol Head Neck Surg 2002;126:499-504.
23. Oeleyiannis FW. Cockcroft BD. Pinczower EF. Exostosm of the external
audiwq m I In Oregon surfers. Am J Otolaryngol 1996;17:303-7.
24. Wong BJ, Cervantes W. D@e KJ, Karamzadeh AM, Boys P, Brauel G.
et al. Prwaleme of extend auditury canal exostoses In surfen. Arch
Otolaryngol Head Neck 5urg 1999;125:969-72.
25. Sander R. Otitis externa: a pmctkal guide to treatment and prevention.
Am Fam Physician 2001;63:927-36. 9414.
26. Ott MC, Lundy LB. Tympanic membrane perforation in adults. How to
manage, when to refer. Postgrad Med 2001;110:81-4.
27. Fagan P, Patel N. A hole in the drum. An m i e w of tympanlc mem-
brane perforations. Aurt Fam Physldan 200t:31:707-10.
28. Dorier 5, Wagner RF Jr, Black SA, Terradna J. Beachfront saeening for
skin Earner in Texas Gulf mast surfers. South Med 1 1997;90:55-8.
29. U.S. Prwentwe Services Task Force. Recommendations and rationale:
munselmg to prevent skin cancer. Accessed online lanuary 24, 2005,
a t http:i/www.ahrq.gov/cllnt~3rdusp1tfIskcammkh~htm.
June 15,2005 Volume 71, Number 12
Arnericav Family Pl~ysician 2317
How can I stay safe while I'm surfing?
The most common surfing injuries are cuts,
sprains, and broken bones. Most cuts are caused
by a surfer's own board. Be aware of your board
and other people around you. You can buy
rubber guards for the side rails and fins to keep
your board horn hurting you o r someone else.
Buy a special helmet made for surfers and wear
it every time you surf (see figure below). A special
surfboard leash can keep your board from hitting
someone else. But it also can make your board
snap back and hit you. Ask an experienced surfer
to show you how to use the leash.
What should I do about cuts?
If you get a t , get out of the water and push
gently on the skin around the cut. If the
skin o r
from Your Family Doctor
bleeding does not stop, call your doctor. Cuts
can get infected from g m s i n the water. See
your doctor if a cut does not stop hurting, turns
red, or has yellowish fluid coming out of it.
Can I do anything to keep from getting
Surfers can get e a r problems, especially if they
surf i n cold water. Using earplugs is the easiest
way to prevent most ear problems.
Strong waves or hitting the water too hard
can break your eardrum. Wearing a helmet and
earplugs can keep this from happening. Water in
your ear canal can cause infections. Make sure
your ears are dry after you leave the ocean.
Surfing in cold water can cause bony
growths in your ear canal. This can lead to
hearing problems and ear infections. See your
doctor if you have ear pain, trouble hearing, or
fluid coming out of your ear.
What else might be dangerous?
Surfers should- be aware of stingrays, coral,
jellfish, and sharks (see figure, page 2). Stingrays
bury themselves in shallow sand. They will stay
away if they know you are coming, If there are
stingrays where you surf, drag your feet through
the sand to keep from stepping on them, If you
get stung, get out of the water right away. Put
hot water on the area where you were stung to
help stop the pain. See your doctor i f the area
keeps hurting or you feel sick
Jellyfish float in the water and can sting you.
They usually travel in groups and are hard to
see. Jell@& stings are painful, and some can
even be deadly. Do not surf when jellyfish are in
TODAYS FAMILY P?lYSICMN - S P E -
IN W OF YOU.
Page 1 of 2
w from Your Family Doctor
Safe Surfing $%iiCd~
Shark very rarely attack people, Common
sense can protect you h m most shark attach.
Do not go into the water i f sharks have been
reported in your area, Do not surf if you are
bleeding or have open cuts. If you see a shark,
get out of the water: Do not try t o touch the
shark Get help right away if you think you have
the water. If you get stung, get out of the water .
right away. Take off any parts of the jellyfish
&at are still on your skin, but do not use your
bare hands. Do not use fresh water to rinse off
the area. Fresh water can make the sting worse.
T r y rinsing with salt water, alcohol, baking soda,
or vinegar. Hot salt water or Rot pack can help
with the pain.'~ee your doctor right away if you
Coral reefs can be dangerous for surfers. Be
aware of how deep the water is where you surf.
Do not surf over shallow coral re& Cuts h m
coral, can be.painfu1 and heal slowly. See your I
doctor if the pain and redness do not go away. "
This information prcwicjes a general wwlew and may not apply t a m
information applj~s tobu a@ to get more infoymatjon on this subject. Copyright@ 2005 American Academy of F a m i l k
Physicians. hdividpls m y photocopy thk daf for their own personal reference, and physidans may p h a -
with their own patients.:Wrihen permidan b required for all other uses, including electronic uses.
Thii handout i s provided td you *your
and t h American Academy of ~mily
Information Is available from the AAFP online at http:/M.fami~or,org.
Talk to your family doctor to find out if thb
f w . ~ ,
, a mjqians'bther
Page 2 of 2