Ouch, That Hurts [46]

Common Arm Injuries in Sea Kayaking

By David Winkworth

What you don’t know can hurt you

In sea kayaking, our bodies are the engines that power the whole show, so not only do we need to keep them operating at peak efficiency but we also need to recognise the first signs of a problem.

We may consider our arms as the linkages from our bodies to the paddle – and our paddles do much more than simply move us through the water… we also use them for steering and support strokes. To perform all these tasks our arms and wrists must move through a broad range of movements.

Injuries to arms and wrists in sea kayaking are not uncommon and even the slightest twinge has the potential to develop into a chronic condition. But long before this occurs, the pain and discomfort  from an injury may be enough to abort that expedition you’ve been planning for months!

I propose in this article to cover three common arm/wrist injuries. I have had the misfortune to have experienced them all, although only one of them was caused through paddling. Two of them required surgical intervention. You will see that none of them are ‘paddling specific’ injuries and you may indeed know people who have experienced these injuries through other sports or through their occupations.

For reports on shoulder problems, I would refer you to Nick Gill’s excellent offerings which can be found in previous issues of NSW Sea Kayaker and on the NSWSKC website.

So, you might indeed be wary of these injuries for yourself, but what if you’re the leader of a Club day paddle or expedition? An expedition is only as fast as the slowest paddler and the slowest paddler may be the slowest because of an arm injury! It is vitally important that you, as leader, are aware of all problems in your group. There is also the responsibility of all paddlers to keep the leader informed of any injuries. Early intervention is the key to a swift recovery.

De Quervain’s Tenosynovitis

Sometimes called simply tenosynovitis, tendinitis or intersection syndrome, it is without doubt the most common arm injury in sea kayaking. It needs to be treated immediately.

What is it?

Tenosynovitis is a painful inflammation of tendons in the wrist caused by friction. It almost always occurs in the wrist directly behind the thumb where two tendons intersect. If you hold your right arm out with palm and fingers vertical, thumb on top, the injury site will be on top of your wrist about where your watch strap would go around. Now, using the fingers of your left hand, pinch the top of your right wrist as you clench and unclench your right hand and you’ll feel the tendons working.

Nerves, ligament

Tendons are fibrous tissue which connect muscles to bone. Some tendons run very close to each other (such as in the wrist). In these locations they are protected and separated by their own sheath which secretes a thick fluid called synovia to lubricate the tendon as it passes up and down the sheath. When a tendon is called upon to work hard it swells slightly and puts pressure on the sheath as it moves. If the sheath is unable to secrete enough fluid to lubricate the tendon’s movements, it dries out (so to speak) and heat develops through increased friction. This is definitely a case of ‘oils ain’t oils!’

If the activity causing the problem continues, there is increased blood flow to the site and quite visible swelling. The area also becomes painful and inflamed. In severe cases, a squeaking noise (called crepitus) can be heard quite clearly. It is a disabling condition which can prevent use of the affected hand altogether.

If the activity causing the inflammation continues, scar tissue can develop in the sheath inhibiting further lubrication. The condition may then become chronic and require surgery to slit open the sheath and remove scar tissue.

What causes it?

Generally, it is caused by rapid repetitious movements of the thumb and wrist and is common in assembly line workers. Interestingly, the occurrence of tenosynovitis in assembly line workers is more common in those workers performing a task for the first time, which leads to the observation that it is also a more common injury for those new to sea kayaking than it is for the old sea dogs (trip leaders should remember this when leading paddles for those new to sea kayaking). The condition can also occur more readily in the old sea dogs who have had a lengthy rest from paddling. It would seem that there is some conditioning factor here and that those returning to paddling after a lay-off should do so gently at first.

In sea paddling, my opinion is that it is almost always caused by holding the paddle too tightly. This may be due to instability, nervousness, strong winds, aggressive steering strokes, etc, and it may only be for a short time but once the inflammation has started, it is highly unlikely that the tendon will repair itself that day.

Trip leaders would be wise to organise experienced paddlers on a paddle to closely observe the paddle grip of those new to sea kayaking. Wind, short steep seas and narrower kayaks may make newer paddlers hold on too tightly. Look for tightly closed hands around the shaft with no relaxation phase during the return.

The condition may also be caused through the use of an unfeathered paddle and the associated wrist cocking, although it’s my observation that the condition occurs equally with feathered and unfeathered blades. In any case, the trend these days in feathered paddles is away from the old ’90 degrees or nothing approach’. Some paddlers are now using feathers of around 45 degrees and I think it’s unlikely that such a small feather angle would contribute to the condition. You can test the tendon work required for gripping tightly versus wrist pronation for yourself: Pinch up the tendons as described above, clench and unclench your fist while noting the tendon tension and movement, then note the tendon movement with wrist cocking as you would do while paddling. Quite a bit less with the latter isn’t it?

Treatment

Like many inflammation type injuries, the first and best treatment is rest. That is, rest the limb from the action suspected of causing the injury. In this case, it is rest from paddling IN CONJUNCTION WITH a splint that immobilises the thumb and wrist. The splint can be made of anything – clothing, bandages… even sticks and duct tape! Anything that stops the tendons moving will be OK.

If it happens at sea and you’re alone, you don’t have much choice – you have to paddle ashore. If it happens to someone in your group, stop them paddling immediately, put some more clothes on them, clip on a line and tow them ashore. What you do there and then will determine whether or not they can paddle tomorrow or the day after. Once ashore, they may still need help with getting out of paddling gear, erecting tent, etc – be aware!

OK, rest, splinting… maybe some anti-inflammatory medication. The next step, if those aren’t successful, is a visit to the doctor for a corticosteroid injection into the tendon sheath. If the doctor gets it in the right place, the relief is instantaneous and that may even cure the problem… as long as the arm is also rested.

Some years ago I had tenosynovitis in my right wrist. I gave it a week off and went back to serious paddling. It wasn’t enough and the condition became very painful, squeaky and chronic. While the success rate in surgical intervention is less than 100%, I did go for it… and I was lucky. It may not be the same for you!

Carpal Tunnel Syndrome

I’ve never seen a serious case of Carpal Tunnel Syndrome (CTS) caused by sea kayaking but, nevertheless, paddlers should be aware of its early stages as it can be quite uncomfortable. CTS is also known as Repetitive Strain Injury (RSI) and I remember its occurrence being common among keyboard operators, hairdressers and process workers. I think that awareness of OH&S issues in recent years has seen the introduction of better work practices and maybe it’s not so common these days.

What is it?

CTS is pain, numbness and tingling of the fingers (thumb and first three fingers only) caused by compression of the median nerve where it passes under the carpal ligaments. Carpal ligaments run across the heel of your hand (on the palm side) just in front of your wrist. Under the ligament, in the carpal tunnel, run veins, arteries, eight flexor tendons and the median nerve. There’s not much room in there and any swelling of the tendons (doing work, remember) can put pressure on the median nerve causing tingling and numbness.

If the pressure in the carpal tunnel continues, the nerve can become scarred, further tightening in the tunnel and leading to pain (especially at night) and ultimately, loss of hand function.

What causes it?

Well, quite obviously, the flexing of the wrist in paddling. I believe this condition would be more common in those paddlers who use feather angles of near 90 degrees. As the wrist is cocked one way and then the other, the tendons in the carpal tunnel are flexed back and forth, they swell slightly and put pressure on the nerve. A tight grip on the paddle shaft may be a cause too.

I’ve seen paddlers with tingling and numbness at sea during rest breaks shaking their hands to restore feeling, believing their problem to be poor circulation or numbness due to cold water. It is most likely these were not the causes of their problems. They were experiencing mild Carpal Tunnel Syndrome.

Treatment

Once again, the best treatment is rest. I used to experience occasional finger tingles at sea and I found that a few rest stops would see the end of them. If the problem persists, longer rests may be needed.

Splinting the hand/s, especially at night is also helpful. Corticosteroid injection into the carpal tunnel is also claimed to be of benefit. In cases where loss of feeling in the hand and fingers is evident, a simple surgical operation to slit the ligament to relieve pressure on the median nerve is performed.

If a paddler in your group complains of tingling and numbness in their hand/s during a long paddle, you could:

  • introduce longer and more frequent rest stops
  • advise them to switch to an unfeathered paddle IF they are using a feathered blade
  • tow them for a while to rest their hands

Tennis Elbow

The medical name for this injury is Epicondylitis. It basically means ‘a lump above the lump at the end of a bone!’ There are two types of Tennis Elbow or Epicondylitis.

They are Medial and Lateral Epicondylitis. The latter is by far the most common injury.

What is it?

Despite its name, Tennis Elbow is not as common among tennis players as you would think. It is common in golfers, bricklayers, squash players and surprisingly violinists.

Tennis Elbow is a tear or overload injury and occurs at the elbow. Hold your arm with the elbow at right angles. On the outside of your elbow you can feel a bony lump about halfway up your elbow. This is a lateral epicondyle (now you know!). Tendons of extensor muscles in your forearm attach to the bone here.

What causes it?

Can you remember ever bumping this bone on a doorway as you’ve walked through and mentioned that you’ve bumped your funny bone? You can? Well, that’s often the start of a Tennis Elbow injury. The tear of the tendon attachment point onto the bone often follows a bump which you may or may not remember. It may be something simple such as opening a jar,  wringing wet clothes or feathering a paddle blade which does the final damage.

Once it’s happened though, you’ll know about it! It can be very painful and simple tasks such as picking up a cup of tea or shaking hands become impossible in severe cases.

There is usually no swelling although the site of the tear is very tender. Normal elbow movement is possible but resisted extension of the wrist upward is painful. Holding up a paddle in one hand can be similarly painful. In fact any action requiring gripping with a palm-down attitude will cause pain.

Treatment

The good news is that the injury will respond to treatment. The bad news is that a full recovery may take 6 months to 2 years!

Rest is the first line of treatment. This should involve RICE (Rest, Ice, Compression, Elevation) as required. Anti-inflammatory drugs are also used if the injury is acute.

Corticosteroid injections are also used and surgical intervention too in severe cases.

Stretching and strengthening exercises are also prescribed during recovery.

I think an unfeathered paddle may assist if the tennis elbow injury is in the right arm.

If a Tennis Elbow injury occurs on a paddling trip, rest would be the first treatment to try. Depending on the severity of the injury, take a few days off, do some walking, read a book perhaps and then try some reduced effort paddling. Above all, listen to your body. More pain will mean a longer recovery.

When you do your pre-paddle stretches and warm-up routine, don’t neglect your hands, wrists and forearms.

If you suffer an arm injury, use commonsense: rest the injured limb immediately and then, as the man says, “If pain persists, see your doctor.”

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