Written by Arvid Schigt (MD), Dion van de Schoot (MD) and Juan Erquicia (MD).

Is it a bird? Is it a plane? No, it’s John John Florence flying towards an ankle sprain… At the start of 2013 ASP Tour, John John Florence had to step back from competing after injuring his ankle.

The lower extremities connect the surfer’s upper body to his board, passing through motions and forces from head, neck, shoulders, arms and trunk which allows him to steer his board in various directions, and with variable speed along the wave. While connected to the board, some specific traumatic surfing injuries may occur. However, even higher risks for injured lower extremities may apply when performing acrobatic techniques such as aerial maneuvers.

In general, analyzing the mechanism of injury will help the physician to predict the extent of injuries, to prioritize decisions, to predict the type of necessary assessments, treatment, and transport. Kinetic energy plays a great part in injury mechanism by means of mass and velocity and according to Isaac Newton “a body at rest will remain at rest, and a body in motion will remain in motion, unless acted upon by an outside force”.

Some of the maneuvers preceding an acute surfing injury emanate from actually riding a wave (62%), and other maneuvers are associated with non-wave-riding activities (38%) [1].

Maneuvers preceding an acute surfing injury

Surfing is an intermittent type of sport consisting of the following activities: 50% of paddling, 40% of waiting for suitable waves, and 5-10% of actually riding waves [2]. The latter also depends on the skills of the surfer with the higher level surfer spending less time on recovering of the board for example. 5-10% of actually riding waves means that the majority of injuries are caused in the minority of the activities of all time spent in the water.

With the increase of aerial maneuvers in today’s surfing, injury mechanism patters will probably change in the future. The EASD invited Dr. Juan Erquicia, orthopedic surgeon (not involved in the treatment of John John Florence), to share his knowledge on John John Florence’s ankle injury and the trauma mechanism of aerial maneuvers in particular.


In recent years surfing has achieved a different dimension.

Simultaneously with the times, the evolution of our sport has become more and more spectacular, and much of this is due to the appearance of the aerial jumps. These sets of highly spectacular maneuvers are accompanied by an enormous physical demand and skill. Its realization is not represented only by air time, but moreover by the power moment to break away from the wave, the actual execution of the exercise in the air, and the time of reception of the forces when making contact with the water again. Probably the latter is physically more demanding and many times associated with joint injuries, primarily in the knees or ankles.

Recently, the spectacular Hawaiian John John Florence, with all his powerful youth, has been the victim of one of these sensational movements during the first day in the Quick Pro Gold Coast Championship, (as seen in the following video)

while he was attempting a reverse aero, he suffered a fall at the time of the reception. In this video -at around 28-30 seconds of its beginning- can be seen how his right foot is slightly off the board. This separation, however minimal, generates a greater impact upon the reception of driving the same load on the joints, mainly in the ankles and knees.

This first contact between the surfer and the water table is controlled by proprioception. This is the interaction that occurs between the joints and the brain, by which the latter decides the contraction / relaxation of the agonist / antagonist and thus achieves balance.


Proprioception is the conscious and subconscious ability to know the position of a body segment in space. Synaesthesia is the ability to feel the movement and direction; integrated with touch, sight and vestibular, proprioception and kinaesthesia, its function is necessary for the body’s posture and joint mobility.

Mechanoreceptors and free nerve endings have been demonstrated in numerous joints (ankle, knee, hip, spine, shoulder, elbow, wrist and fingers). Freeman and Wike receptors classified as type I (Ruffini endings), II (Pacinian corpuscles), III (Golgi receptor organs) and IV (free nerve endings).

As other body functions, the proprioceptive system deteriorates with age.

The ankle and the proprioceptive system

Different receptors have been found in the capsule and ligaments of the ankle by Freeman and Wike (1967). An effective proprioceptive system is important to prevent ankle sprains.

The injury frequently occurs in plantar flexion and inversion of the ankle, with consequent distension of anterior talofibular ligament, calcaneofibular and posterior talofibular ligament. The role of the muscles peroneus brevis, peroneus longus, and the anterior tibial and ankle stabilizers assets is very important.

A sprain is an event usually happening very fast, so a quick response is valid and necessary to prevent an injury. The latency of muscle contraction is an index to test the proprioceptive system.


Proprioception can be trained in order to improve joint mobility, muscle reaction speed, improve the quality of muscle contraction, as well as an improvement of the overall body plan and thus reduce the number of injuries, improve time recovery and performance.


There are different types of treatments accepted, thanks to its good results, according to the degree of joint instability experienced.

In those minor episodes of instability, as in the case of John John Florence, orthopedic treatments have evolved into increasingly functional fixed assets, with better results in less time [3].

Similarly, in cases of total rupture of the lateral ankle ligaments, functional fixed assets provide safer and faster results than strict type plaster immobilization, which is of vital importance in sports patients [4].

However, when comparing conservative therapy vs. surgical treatment in orthopedic injuries of the total lateral ankle ligament complex, long-term results are superior in those patients operated with less pain and less residual numbers of episodes of recurrent instability [5].

Take-home message

Just as the world and medicine, surfing is also evolving. Boundaries are always tested. The desire, the ambition to improve ourselves and the competitive spirit lead us to demand from our body the most, very frequently.

Regardless of whether we are thinking of an aerial or not, it is important to know and accept our limitations, and above all never lose respect for the environment around us.

This will lead to decrease the number of injuries, and when we bear them or treat them, start to accept and face them courageously.

Best regards,

Dr. Juan Erquicia.

Reference List

(1)   Nathanson A, Haynes P, Galanis D. Surfing injuries. Am J Emerg Med 2002 May;20(3):155-60.

(2)   Taylor KS, Zoltan TB, Achar SA. Medical illnesses and injuries encountered during surfing. Curr Sports Med Rep 2006 Sep;5(5):262-7.

(3)   Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med 2005 Feb;39(2):91-6.

(4)   Ardevol J, Bolibar I, Belda V, Argilaga S. Treatment of complete rupture of the lateral ligaments of the ankle: a randomized clinical trial comparing cast immobilization with functional treatment. Knee Surg Sports Traumatol Arthrosc 2002 Nov;10(6):371-7.

(5)   Pijnenburg AC, Bogaard K, Krips R, Marti RK, Bossuyt PM, van Dijk CN. Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomised, prospective trial. J Bone Joint Surg Br 2003 May;85(4):525-30.



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