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Outrigger canoe paddling is a very popular competitive sport in the Hawaiian Islands and Polynesia. The sport is growing rapidly in Australia and the mainland US.
To assess the types and severity of musculoskeletal injuries and medical conditions that affect adult outrigger canoe paddlers on (O`ahu, Hawai`i.
A survey was designed to assess outrigger canoe paddling injuries and medical conditions based upon a literature review of medical conditions that affect other paddling sport athletes (e.g., rowers, kayakers, and canoeists). The data were compiled and analyzed using statistical software.
Surveys were completed by 278 (142 women, 145 men) (9.5%) of the 3,068 registered (O`ahu adult paddlers during the summer of 2006. The subjects’ mean age was 39 years (range=18–72 years). Sixty-two percent of respondents had experienced paddling-related musculoskeletal injuries. The most common sites of involvement were shoulder (40%), and back (26%), followed by wrist/hand (10%), elbow (9%), and neck (9%). Forty-nine percent of participants experienced skin lacerations, 33% developed heat illness, 32% sustained injuries from exposure to coral or sea creatures, and 24% developed skin infections. Ten percent of subjects reported prior histories of skin cancer or precancerous lesions. There was no statistically significant increase in injuries when comparing age groups, sex, or boat position. There was a statistically significant increase in the number of injuries in those that paddled in the long and short distance seasons over those that paddled only short distance. Short distance races are sprints less than 2000 meters and long distance races are endurance events usually 20 to 30 kilometers with some more than 40 kilometers. There were also more injuries reported in the first season compared with the second season and in the third or later season as compared with the second, although this may be due to limitations of the survey design.
Outrigger canoe paddlers report a high prevalence of musculoskeletal injuries and illnesses related to their sport. The shoulder and back were the most common sites of injury. The rib was the most commonly fractured bone. Paddling may also predispose to such environmentally related conditions as heat illness, injury from sea creatures, and perhaps skin cancers.
To the authors’ knowledge, this is the first study to identify the medical conditions that affect adult competitive outrigger canoe paddlers on (O`ahu. The findings will help paddlers, coaches, and medical practitioners to better identify and understand paddling-related injuries and illnesses.
Outrigger canoe paddling is an extremely popular sport in Hawa`i and Polynesia. Among the 10,000 outrigger canoe paddlers in the Hawaiian Islands, more than 4,000 adults and children are registered participants within two O`ahu outrigger canoe racing associations.1,2,3 Outrigger canoe paddling is also spreading rapidly to parts of the mainland United States, Australia, New Zealand, and Japan. The Hawaiian-style outrigger canoe (w`a in Hawaiian language) differs from a traditional Olympic-style canoe by the presence of a stabilizing outrigger float (ama). The ama is attached to the canoe hull via two perpendicularly oriented struts (iako).2 The ama provides stability of the canoe, but introduces much less hydrodynamic inefficiency than making a single hull canoe wider. Compared to other types of canoes, outrigger canoes can be quite fast, yet are also capable of being paddled and sailed in rough water.
The first outrigger racing canoe was commissioned for construction by Prince Kuhio of Hawa`i and won numerous races between 1907 and 1910. Outrigger racing canoes were abundant in Hawai`i by the 1930s. Races are conducted both as point-to-point open water (long-distance) events and as short-distance (regatta) contests in which each canoe completes laps within a designated racing lane over a one-quarter to one-half mile course. Most outrigger canoe team competitions utilize six-person canoes. Athletes occupying the first five seats, paddle on alternating sides of the canoe, while the rear seat is taken by the steersperson who captains the canoe, motivates the crew, and sets the canoe up for the best course to catch the swells. Special outrigger canoe races are conducted for one-person or two-person (tandem) outrigger canoes.
The short distance season begins in late March or early April with daily pr actice training for one or two hours. The regatta season consists of weekly races throughout June and July with the championships held in August. The races range from 500 to 2000 meter sprints and take place from 8:00 AM to mid-afternoon depending upon the age range competing. Younger paddlers compete earlier.
The long distance season begins in August after the completion of the short distance season. Training is held daily and races are weekly throughout August and September culminating in womens’ and mens’ Moloka`i Hoe races from (O`ahu to Moloka`i held two weeks apart. Race lengths are generally 20 to 30 kilometers. The Moloka`i Hoe is > 60 kilometers.
A search of the PubMed MEDLINE database using search terms “canoe,” “kayak,” “outrigger canoe,” and “paddling” identified numerous studies of Olympic-style canoeists and kayakers but only two studies of outrigger canoe paddlers. This review confirms that all forms of canoeing and kayaking rely on upper body strength and conditioning and require repetitive motion of the joints of the shoulders, elbows, and wrists. Paddling exercise is potentially aerobic and/or anaerobic in nature depending on the length of the event.4 A survey of hard shell Whitewater canoe and kayak paddlers identified that the shoulder, wrist/hand, and elbow/forearm to be the most common injury sites, sprain/strains as the most frequent injury types, and that 36%–47% of paddlers sought medical attention for these injuries.5 Among 500 British long distance kayakers, 23% experienced wrist tenosynovitis after a long distance event.6 The most common sites of injuries among rowers were the low back, ribs, chest wall, shoulder, forearm, and wrist.7 Additional reports document a high incidence of facial traumatic injuries during Whitewater canoeing and kayaking,8 and frequent occurrences of sprains, tendonitis, and chronic musculoskeletal pain in competitive Olympic paddlers.9
The two previous outrigger canoe paddler studies utilized Australian outrigger canoe paddlers. Stanton et al. surveyed 101 outrigger canoe paddlers and found that most supplemented their canoe training with cross/strength training, a majority used ergogenic aids, and 49% reported injuries from paddling, with the most common sites being the shoulder and lower back.10 Humphries, et al. evaluated 21 outrigger canoe paddlers for body stature, aerobic power, and muscular strength and force, to conclude that measurements were similar to those of athletes in other water craft sports and that muscular imbalances may provide a vulnerability to musculoskeletal injuries.11 As a result of the review of the two previous articles, questions on crosstraining, and injuries to back and shoulder were added to the survey. Review of these articles also lead us to hypothesize that injuries to outrigger canoe athletes would be similar to those of other rowing sports based on the similarities in body measurements. Therefore we focused the survey to include common injuries encountered by other paddling disciplines. The purpose of this survey study is to identify characteristics of a large sample of adult competitive outrigger canoe paddlers on O`ahu and their histories of paddling-related injuries and medical conditions.
Websites of the two major (O`ahu-based outrigger canoe racing associations—the (O`ahu Hawaiian Canoe Racing Association (OHCRA) and Hui Wa`a--were consulted to identify club contact information for the 2006 summer regatta outrigger canoe racing season.12,13 Ten outrigger canoe clubs (6 from OHCRA and 4 from Hui Wa`a) initially agreed to voluntarily provide subjects for participation in the survey study. Surveys were distributed at practices and regattas. In addition, paddlers from other clubs were approached during four different summer weekend regattas. Investigators visited each paddling clubs’ tents several times during each event to identify new subjects over the course of the day. To preserve confidentiality, subjects were given the option of returning the surveys to an empty box left in their tent or by mail. Surveys returned at the practices or regattas were collected within one hour of distribution. Participation was strictly voluntary. For inclusion in the study, subjects must be registered (OHCRA or Hui Wa`a) for the O`ahu outrigger canoe racing season, and age 18 years or older. Exclusion criteria were illegible survey completion and age less than 18 years. The study received approval by the Hawa`i Pacific Health Institutional Review Board (RP #06-042-2HPH41) and the University of Hawa`i Committee on Human Studies (CHS#14455).
A survey was designed to assess injuries and medical conditions that affect outrigger canoe paddling based upon a literature review of medical conditions that affect other paddling sport athletes, and through consultation with sports medicine physicians and experienced paddlers on O`ahu. The survey instrument was reviewed by a senior academic physician clinical researcher, academic sports medicine physician (co-investigator), and biostatistician.
The survey obtained general data on subject age, gender, ethnicity, paddling position(s), paddling experience, paddling frequency, other training activities, and any chronic medical conditions. Each subject was also asked to provide details of any paddling-related medical conditions including those affecting the skin (sunburn, skin cancer, infections, lacerations, marine organism injuries, etc.), head (concussions, trauma, etc.), heat injury, and gastrointestinal illnesses. Further details were obtained concerning all prior paddling-related musculoskeletal injuries by site, injury type, types of treatment(s) received, and significance of disability.
The data was complied and analyzed using spreadsheet and statistical software, SAS version 9.1, with the assistance of biostatisticians.
Overall, 293 of the 320 surveys distributed were collected, for a response rate of 92%. Thus, 9.5% of the 3068 adult paddlers (54% men, 46% women) officially registered for the 2006 O`ahu summer regatta season participated in the study. The subjects’ mean age was 39 years (range= 18–72 years).
The participants’ self reported ethnicities were Caucasian 57%, Asian 41%, Pacific Islander 26%, American Indian 4%, African American 1.4%, and other 8%. The sum is greater than 100% as some subjects identified with more than one ethnicity.
Only 26 (8.9%) survey participants reported having chronic diseases, such as asthma (5%), hypercholesterolemia (3%), hypertension (2%), deep venous thrombosis (2%), and alcoholism, cancer, diabetes, hypothyroidism, liver disease, lung disease, osteoarthritis, heart disease, stroke, systemic arthritis, and ulcerative colitis (1% each). Sixty-two percent of respondents had experienced paddling-related musculoskeletal injuries. The most common anatomic sites of involvement were shoulder (40%), back (26%), wrist/hand (10%), elbow (9%), and neck (9%). There were no statistically significant differences in the numbers of injuries sustained by age, gender, or canoe seat position. Heat illness was reported by 33% of participants. Skin ailments also occurred frequently wit h skin lacerations affecting 49%, injuries from exposure to coral or sea creatures experienced by 32%, and non-coral related skin infections noted by 24%. Ten percent of subjects reported being diagnosed with skin cancer or precancerous lesions. Among the 15 survey participants who had experienced paddling related bone fractures, 11 involved the ribs, two the wrist/hand, and one each affecting the head/neck, back, and ankle. (See Table 2)
When questioned about the duration of musculoskeletal injuries sustained, 49.9% reported symptoms that lasted for one week to one month, 10.8%, for less than one week, 24% for one to two weeks, 25% for two weeks to one month, 33.6% for longer than one month, and 6% had developed permanent symptoms. (See Table 3)
Although a majority of survey participants (55.8%) did not seek treatment for paddling related injuries, 35% consulted a physician, and 2% visited a hospital emergency department. Most reported musculoskeletal injuries (47%) did not limit paddling participation or activities of daily living, 36% experienced mild disability which only interfered with exercise, 14% had moderate disability that also interfered with daily function, and 2% suffered a severe disability that prevented them from working or going to school. (Table 3).
Paddlers who participated in the long distance season reported significantly more musculoskeletal injuries (143/279, 51%) than those paddlers who did not paddle long distance (38/279,14%) (c2=16.15, df=l, p <.0001). (Table 3)
Paddlers also experienced significantly more paddling-related injuries during their first season or third or later season of paddling compared to the second season of paddling (c2 =0.93 and 0.15 respectively, df = 1, p <.001 for both). (Table 4)
To our knowledge, this is the first study to examine adult outrigger canoe paddling-related injuries and medical conditions. The survey group was diverse in regards to gender, age, and ethnicity. Musculoskeletal injures were common in this survey population but most were mild in severity and short in duration.
There was a statistically significant increase in the number of injuries in those that paddled in the long and short distance seasons compared to those that paddled only short distance. The higher incidence of injuries found in long distance paddlers is likely due to the increase in repetitive movements, cardiovascular and muscular stress, water exposure, and lack of a substantial rest and recovery period between the consecutive short and long distance seasons.
The higher numbers of injuries described during the first season or third or later seasons of paddling may be due to limitations in the wording of the survey. Perhaps, paddlers are more likely to remember during their inaugural paddling seasons and may be less able to differentiate between subsequent seasons. This finding may also be attributed to relative lack of conditioning, experience, and or proper technique used in the first season of competition. Further, the observed increase in injuries during the third or later paddling season may be due to increased training volume or the additional participation in the long distance paddling season.
The shoulder was the most commonly reported site of musculoskeletal injury in our study as well as in white water kayakers. This differs from injury reports of rowers who most commonly injury their backs. Rumball et al suggest that the high incidence of back injuries in rowers is produced by the repetitive spine flexion that is characteristic of rowing but limited in outrigger canoe paddling.7
The high rate of rib fractures found in this study is consistent with previous studies on rowers that report 6% to 12% incidences of rib stress fractures.14,15 Our survey did not differentiate between overuse related rib stress fractures and acute traumatic rib fractures. Most subjects reported “cracking a rib” which suggests acute traumatic etiologies. Perhaps, undiagnosed stress injuries are leading to an increase in rib fractures in outrigger canoe paddlers.
Previous episodes of heat-related illness was prevalent in the study population. Unfortunately, the survey did not differentiate between various severities of heat illness. Heat-related medical conditions are exacerbated by warm temperatures, low wind velocities, sun exposure, and inadequate fluid intake while paddling.
The canoe seat position did not seem to influence the frequency of paddling related injuries. Seat position has influenced rates of injuries in other water sports. Preferred seat position may be less important in outrigger canoeing as paddlers often switch seats, with the exception of the steersperson.
A limitation of this study is that survey instrument is not validated and requires a recall of injuries and illnesses that have affected a study participant. Other limitations include the exclusion of non-registered former paddlers, some of whom may have experienced serious, career-ending injuries, and a recent sewage spill into a common practice site waterway that could have increased the numbers of skin infections.
In summary, the results show that musculoskeletal injures are common in outrigger canoe paddlers, and that most injuries are mild in severity and short in duration. Additionally, paddlers participating in both the long and short distance seasons sustain more injuries than those that participate only in the short distance season. The rib is the most commonly fractured bone in paddlers, and more injuries occur during the first or third or later season of than during the second season of paddling.
Hopefully this study will help paddlers, coaches, and medical practitioners to better identify, understand, and prevent paddling-related injuries and illnesses. Medical practitioners should suspect rib injuries in paddlers and encourage rotator cuff and core strengthening to prevent overuse injuries of the shoulder and back. Coaches should reinforce proper paddling techniques and consider teaching a paddling stroke that decreases the amount of force on the serratus anterior and external oblique muscles to decrease the risk of rib stress injury. 14 Paddlers should be encouraged to drink to thirst and replace electrolytes during long distance races and frequently be assessed for signs and symptoms of heat illness to prevent life threatening increases in body temperature and heat stroke. Paddlers should aggressively seek sun protection and have lacerations and skin injuries properly cleaned and evaluated by medical personnel if there are signs of infection. Finally, paddling officials and race coordinators should have a documented emergency plan in place that is practiced regularly and includes strategically placed automated external defibrillators.
Prospective studies with large sample sizes are still needed to properly assess the medical risk and benefits of outrigger canoe paddling. It is our hope that data from this study will enforce the need for preparation and precaution in this sport and encourage future generations to participate in this unique part of Hawaiian culture safely.
Supported by a Research Centers in Minority Institutions award P20 RR11091, from the National Center for research NIH. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCRR/NIH.