Pain: Prevention and Recovery

April-May 1999

This is an article from WaveLength Magazine, available in print in North America and globally on the web.

by Paul Nicolazzo

Tendonitis and low back pain are the bane of athletes everywhere, including paddlers.

For paddlers, tendonitis begins as mild pain in the wrists or elbows and often gets worse. Back pain usually begins in the lower back and then moves upward. In the early stages, if you are like most of my paddling friends, you pop some pain and anti-inflammatory drugs and go paddling. And this works for a while. Maybe it even fixes it. But sometimes, it gets worse. Then, all too soon, there comes a time when you want to paddle, you are craving to get into your kayak and just go... but it just hurts too damn much. Questions flood your mind: "What can I do?" (the loudest question), "I want to paddle this weekend." (maybe a bit louder), and "I don't want to make it worse." (usually much, much softer). More drugs seems to be the logical (and easiest) choice. But eventually the drugs don't block the pain anymore and it hurts so bad that one weekend, instead of getting into your kayak, you go see your doctor. At this late stage your doctor may suggest cortisone shots, low level strengthening exercises, and no paddling... for months!

If you are a passionate paddler, the above advice is not what you want to hear (much less follow). But you've known for some time now that this was a likely possibility. Especially since the pain, usually accompanied by swelling and tenderness, has been getting worse rather than better.

The Problems

Because of the forces involved in our chosen sport, paddlers tend to get tendonitis of the wrist or elbow and strain their lower backs. Tendonitis is an inflammation of the tendon. Similar to the construction of a climbing rope, tendons are made up of long fibers (collagen rather than nylon!) and surrounded by a sheath. They connect muscle to bone and are indirectly responsible for movement. Movement begins when the brain sends signals to individual muscles to contract. As the muscle fibers shorten they pull on the tendon which in turn pulls on the bone causing movement. The sheath helps keep the tendon on track during this process. A lubricating fluid between the tendon and its sheath keeps everything running smoothly. Overuse and age causes the fibers to break down, weaken, and eventually interfere with the normally smooth process of movement. Incomplete healing causes scarring and thickening of the tendon and exacerbates the problem. The result is pain, swelling, and tenderness at the origin or insertion of the abused tendon.

Back injuries are usually a result of muscle strains. During normal use, small tears occur in the muscle tissue and lactic acid builds up in the muscle cells. You experience this as a tired muscle. With normal rest and reasonable nutrition, the lactic acid is removed and the muscle cells rebuild, usually stronger than before. During over-use many more muscle fibers are broken and LOTS of lactic acid builds up. The two combine to cause swelling, pain, and tenderness. A sore, stiff back.

Prevention

Conditioning, technique, and equipment are all factors in tendonitis and back strains. Age, too, plays a significant role. Young paddlers tend to have fewer problems because their tendons, muscles, and connective tissue are more resilient.

Conditioning

Since the occasional paddler is more prone to problems than one who paddles more often, conditioning is important. Regular exercise will go a long way in avoiding both tendon and muscle injuries. Weight lifting, yoga, and exercises using rubber tubing for resistance are all good ways to train.

When training to avoid tendonitis in your wrist or elbow, choose exercises that work all aspects of each joint: flexion, extension, and rotation. You want to strengthen your tendons slowly. Because muscles gain strength much faster than tendons (weeks versus months due to their increased blood supply) its very easy to overtrain. Go slowly.

When conditioning your back you will want exercises that both strengthen and stretch your entire back, stomach (all abdominal muscles), hamstrings, and your iliopsoas. Rowing machines work well for strengthening both back and abdominal muscles. They have the added benefit of conditioning your forearms and tendons as well. Use a light setting and focus on a slow easy rhythm. Remember that the muscles in your back, abdomen, and forearms will develop faster than the tendons in your wrists and elbows. Don't over train or you may create the problems you are trying to avoid!

Yoga is especially good for your back since it develops both flexibility and strength. Good nutrition is also important; eat a balanced diet. When the weekend (or expedition) finally arrives, remember to choose route and sea conditions appropriate to your strength. Avoid the common error of "This will make me stronger." This is good way to get injured.

Technique

Generally, good technique requires good instruction. It's very difficult to learn from a book or article. The muscles of your stomach and back are much stronger than those of your arms. Use them. In order to engage them safely, first make sure your boat is properly outfitted (see below). Choose an upright or slightly forward paddling position. Use your legs to support and add power to your stroke. Keep your shoulders in front of you; they should be directly above or slightly in front of your hips as you finish your forward stroke. Avoid the tendency to lean back (behind the plane of your hips) at the end of your power stroke. Your arms should be slightly flexed and remain that way as your stomach and back do the work. Avoid bending your elbows during the power phase of your stroke. Keep your hands relaxed. Paddling in this manner reduces the strain on the muscles and tendons of your forearms and wrists.

There are two different forward paddling techniques; both have their advantages and disadvantages. Alternate between the two, according to your need. For long paddling days in reasonably gentle conditions, keep your paddle shaft low and close to your deck (just in front of your belly) as you take each stroke. Paddle with your shaft as horizontal as possible while keeping your blades completely in the water. Use a modified sweeping action. For power and fast acceleration, raise the paddle to mid-chest height and keep the shaft more vertical and the blades as close to the boat as possible. The stroke should follow the keel line with little or no sweeping action.

With both techniques there are two ways you can position your hands: close together (shoulder width) or much farther apart. The wider your hands are apart the more you engage your back muscles and reduce force on your wrists and elbows. Unfortunately, you also restrict movement in the shoulder joint thus increase the potential for injury there when paddling in difficult conditions. In addition your turning and bracing strokes are less efficient. Therefore, vary your technique according to your needs. I paddle with my hands at shoulder width when playing in the surf or paddling in big water where a fast brace may be needed to keep me upright. Alternately, I paddle with my hands further apart on long gentle tours to reduce the strain on my elbows and wrists.

Equipment

Choosing an appropriate paddle will go a long way in reducing wrist, elbow, and back injuries. A paddle with little or no feather (blades set to different planes) will significantly decrease wrist movement and reduce wrist injuries. At the most, choose a paddle (or set it, if adjustable) with a 45 degree feather. Anything more is asking for trouble. Blade size is another crucial factor in avoiding wrist, elbow, and back injuries. The larger the blade the greater the resistance. Its that simple. Choose a smaller blade size and you will significantly reduce the forces on your wrists, elbows, and back. The same is true of the shaft length. Your paddle shaft acts as a lever. As you increase the length of the lever you put more force on the fulcrum. One of your hands is always the fulcrum. Force that enter the hands must travel through the wrists, elbows, shoulders, and back before being transferred to your boat.

Most beginner and intermediate paddlers choose a large blade and long shaft because it's easier to roll. It's also easier to get injured. For this reason, many advanced paddlers choose a shorter paddle shaft and smaller blade. Again the choice is yours. Consider going to a sea kayak symposium and sampling a range of paddles. Experiment.

A well outfitted kayak is crucial to avoiding back injuries because it supports good technique. You should have well padded and comfortable knee braces. Your foot braces should be strong enough for you to exert a light to moderate backward pressure while you are paddling so you can maintain an erect posture in difficult seas and add power to your stroke. Your seat and back support should support your pelvis comfortably (but firmly) with little or no arch in your lower back. Be careful not to choose a rigid back support that restricts motion. You should be able to lie comfortably on your rear deck without your back support biting into you.

Treatment

Okay, maybe you ignored all my advice about prevention and now you have wrist tendonitis, elbow tendonitis, or a back strain. Or maybe you followed my advice and you still have problems. Regardless how you got here, you're here now. In pain. And wanting to paddle. So what do you do?

There are two distinct phases to your treatment. Let's call them the acute stage and the recovery stage. During the acute phase (you are not going to like this), you stop paddling. And stop training. Now. Your tendons (or muscles) need rest to repair themselves. Paddling and training do not count as rest. If the injury is new, hurts a lot, and you can't use the joint without pain, consider immobilizing it with a splint. A SAM splint (made from padded aircraft aluminum) is fast, portable, and easy to use. It works well with injured wrists. Do not use tape to attach the splint to your body. There is a high likelihood that the swelling will increase over the next 24 hours. Use rolls of gauze or cloth to hold the splint in place; loosen them if the limb swells. An elbow is best splinted by tying it closely to the body with the patient's shirt, jacket, or strips of cloth. Next, and until the swelling goes down, rub the injured area with ice for 20-30 minutes 3-5 times a day. Make sure to give enough time between icing sessions (a minimum of 90 minutes) to allow the tissue to warm back up. (It would be nice to avoid frostbite!)

If you can elevate the affected area above the heart, do so. This will help reduce the local swelling and decrease the healing time. Non steroidal anti-inflammatory drugs (NSAIDs) can be used during this phase. They include aspirin, ibuprofen, and neproxin sodium. A poultice of arnica and comfrey will also help. Steep the raw herbs in boiling water, wrap in a compress, and apply hot to the injured area 2-3 times a day.

You have entered the recovery phase when all the pain, tenderness, and swelling have disappeared. This may take days or weeks. This is where most people screw up and make everything worse. Usually they end up back in the acute phase again and have to start their treatment over. If you blow it enough times in this phase you may never get a complete recovery. During the recovery phase, you stop taking the pain and anti-inflammatory drugs and begin using the limb. Start with simple stretching, gradually move to isometrics, and then to other more aggressive strengthening exercises (including paddling!). Use pain and swelling as your guide. If it hurts, stop. Right away. This is not "no pain-no gain." You are recovering from an injury. This takes time and patience. If after a training session you have pain and swelling (remember...swelling may develop over the next 24 hours), you have just been catapulted back into the acute phase. Remember that while in the acute phase you are again resting the injured area. This means no training (or paddling) until the pain and swelling are completely gone (again). Damn. (I have said this, and many other more descriptive words, numerous times during the treatment of my own injuries. I mention this in case you suspect that you are the only stupid patient out there. Obviously you're not. You are one of many. But that won't help you heal faster.).

Ultimately, if you follow this advice you will recover fully in less time than it would take if you have to cycle through the treatment regime numerous times because you were "in a hurry to get well." Complete recovery may take weeks or months. While muscle strains can completely heal in a three to four weeks, most tendonitis takes a minimum of three months, and in some severe cases, years.

During your healing process you will have enough time to examine why you got injured and what changes you should make in your training, technique, or equipment to avoid the problem again. Obviously, it's much, much easier to avoid getting injured than to treat the injury.

Paul Nicolazzo is Director of the Wilderness Medicine Training Institute, Box 11, Winthrop, WA 98862. He has been an avid paddler (primarily whitewater) for over 22 years. ©