Surfing doesn’t look like a high-impact sport. Besides the occasional bump to the sand, reef or another’s board, surfers don’t have much to worry about (excluding some aquatic life). But ask any surfer with a few years in the water and they’ll usually have a list — a shoulder that burns paddling out, a lower back that tightens up after a long paddle session, a knee that hasn’t quite recovered completely.

That’s because surfing loads the body in ways it wasn’t really built for: long periods of spinal extension, repetitive overhead paddling and explosive movement on take-off, and cold water exposure that most people don’t think twice about. None of it looks dramatic in the moment. Most of it adds up over months and years.

Here’s what we see most often in the clinic, and what’s actually driving it.

1.  Lower Back Pain

This is the most common complaint we hear from surfers, and it usually isn’t from one bad wipeout — it’s from paddling.

Paddling puts the lower back into sustained extension for long stretches, often with the neck also lifted back to see the horizon. Add poor thoracic (mid back) rotation or weak core control, and the lower back ends up doing work it shouldn’t have to. Over time this shows up as a dull ache after sessions, sometimes tightening into something sharper.

The fix isn’t “core strength” in the generic gym sense — it’s building extension/rotational control through the mid-back, so the lower back isn’t compensating for stiffness elsewhere.

2.  Shoulder Pain

Paddling is essentially thousands of repetitions of an overhead movement, done in open water with no real technique coaching for most surfers. That repetition, combined with the internal rotation bias of the paddling stroke, is a well-known setup for shoulder rotator cuff related pain.

It often starts subtly — a twinge reaching for the next stroke, or discomfort duck-diving. Left alone, it tends to get louder rather than quieter.

3.  Neck Pain

Closely linked to the back and shoulder issues above. Holding the head up in extension while paddling — for sometimes hours a session — loads the neck and surrounding musculature in a position it isn’t designed to sustain. Surfers with limited thoracic extension end up relying even more heavily on the neck to lift the head, which makes this worse.

4.  Knee Injuries

Less about overuse, more about single moments — a bad landing off a section, an awkward duck dive, a board hitting the leg at an angle. The twisting and loading involved in take-offs and turns can stress the ACL, MCL, or meniscus, particularly as boards get shorter and manoeuvres more explosive.

These tend to be the injuries that actually stop someone surfing altogether, simply because the knee doesn’t tolerate the loaded, rotational nature of the sport while healing.

5.  Rib and Mid-Back Strains

Common after wipeouts, but also from the rotational forces of turning and popping up. The ribcage and mid-back  also take a lot of unseen load from normal surfing mechanics — bracing through impact, breath-holding through duck dives, extending through paddling. Intercostal strains and thoracic joint irritation are frequent, and often get written off as “just bruised” when the actual issue is a rib or segment that isn’t moving properly and is now guarding.

This one’s easy to under-treat because it usually settles on its own — but “settling” often just means the surrounding muscles compensate, which feeds back into the shoulder and neck issues above.

The Common Thread

Most of what shows up on this list isn’t from a single wipeout — it’s cumulative load in positions the body wasn’t built to sustain for hours a week, year after year. That’s actually good news: cumulative problems respond well to targeted intervention, because you’re not fighting one traumatic event, you’re addressing a pattern.

If any of this sounds familiar, it’s worth getting a physiotherapy assessment rather than assuming it’s just part of surfing. A lot of these issues are very manageable once someone identifies what’s actually driving them.

What Can Physio Do to Help?

For most of what’s on this list, physio isn’t just about calming things down after they flare — it’s about finding why that particular joint or muscle group is under load in the first place, then rebuilding capacity so it stops happening.

In practice that usually means a movement assessment (paddling posture, thoracic rotation, hip and shoulder mobility), hands-on treatment where it’s needed to settle acute irritation, and a specific loading or mobility program aimed at the actual limitation — not generic exercises. For the more mechanical injuries (knee, rib), it also means guiding a safe return-to-surf timeline so you’re not back in the water before the tissue can handle it.