Shoulder Pain Management in Surfers: Lessons for All Physios

Shoulder pain is one of the most common complaints among paddling athletes such as surfers.

The repetitive demands of paddling, and the fact that symptoms often only appear after prolonged activity, make shoulder pain challenging to assess and manage in the clinic. In this blog, we explore how Dr James Furness approached a real case of persistent shoulder pain in a surfer, highlighting key assessment insights for paddling-related shoulder pain and how this case translates into valuable lessons for shoulder management overall.

If you want to see exactly how an expert physio assessed and managed a surfer with persistent shoulder pain, check Dr James Furness’ full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

What we need to understand about paddling

When a surfer came to James with ~3 months of pain in his right anterior shoulder aggravated by sudden movements, and surfing-specific movements such as paddling and duck diving, James’s background knowledge and experience in surfing equipped him well to help this patient.

But for all of us physios that don’t have an in-depth understanding of the mechanics of paddling, James breaks it down perfectly for us. Watch this video from his Case Study:

This is a great reminder that for shoulder pain, activity profiling can really help! Understanding what your patient actually does — in this case, the long slow paddling and quick bursts — is a great starting point. It helps you know what to test and where to focus rehab. Surfers’ shoulders need to sustain load for extended periods, so a brief strength test might miss the issue entirely.

What assessment revealed

On examination, there were no obvious differences in muscle bulk or gross weakness. Flexion and abduction were both reduced by about 20 degrees on the painful side. Strength testing was normal (5/5) and didn’t reproduce pain.

However, when James later tested endurance with a targeted posterior shoulder endurance test, the patient reported pain after 50 seconds. This was a key finding, highlighting that the shoulder’s capacity to sustain load over time was compromised.

The working diagnosis was biceps tendinopathy combined with posterior shoulder tightness. James reasoned that both contributed to the patient’s symptoms during paddling, with the biceps tendon irritated by repetitive loading and posterior tightness restricting scapular mechanics and increasing strain. See James explain his clinical reasoning behind the posterior shoulder tightness in this video from his Case Study:

Targeted rehab based on clinical reasoning

Knowing the pain only appeared with prolonged activity, James prescribed posterior shoulder/thoracic endurance exercises tailored to surfing. The goal was not just to build strength but to improve the shoulder’s ability to tolerate long periods of load without pain.

He also included thoracic mobility exercises, which were relevant both to surfing and to counteracting the effects of the patient’s office work on his shoulder function.

What we can all learn from this case

First off, it shows us exactly how an expert assesses and manages shoulder pain in a surfer, invaluable if you treat surfers regularly. But even if surfers aren’t your usual patient group, there are some key lessons that apply broadly:

1 – Don’t rely solely on short-duration strength tests: Sometimes pain and dysfunction only appear when the shoulder is under sustained load. Understanding this means tailoring your tests to reflect the demands that actually trigger symptoms.

2 – Break down the activity with activity profiling: If your patient’s pain shows up mainly during a specific activity, analyse that activity’s key physical demands. This helps you know what to test and what to target in rehab.

3 – There’s often more than one issue at play: Shoulder problems rarely have a single cause. Recognising how multiple factors interact allows for a more effective, comprehensive treatment plan.

4 – Match your exercise prescription to the activity’s specific demands: It’s not just about building strength. Consider the different ways the shoulder is loaded (e.g., speed, position, endurance) and tailor rehab accordingly.

Wrapping up

The demand on the shoulder in paddling athletes is high, which makes rehab and return to full pain-free function tricky.

But by really understanding those activity demands and planning treatment around them, you can get great results. This case is a great reminder that shoulder management always needs to be patient-specific, by understanding the patient’s symptoms, and really breaking down the activities contributing to them. This approach sets you up to deliver a clear, personalised and effective treatment plan for your patient.

Watch James’s full Case Study to see how he assessed and managed this patient back to surfing.