It is a crisp spring day out in the San Francisco Bay with stiff off-shore easterly winds blowing gusts of up to 50 knots. You are out in 3 foot chop and just hammering through a confused ebbing tide current. After one really forced jibe, your shoulder gets a twinge. Next thing you know, you are in the water. Now what?

Nothing is more discouraging than feeling pain or weakness in the shoulder every time you jibe or water-start. The repetitive stresses of pulling, twisting, and hanging has the ability to overload the muscles of the shoulder and potentially cause injury. These injuries can be of acute nature, such as a sudden tear of the rotator cuff muscle due to a blowing gust while in lay-back position; or chronic injuries such as impingement from repetitive jibing.

The shoulder is a complex ball and socket joint which relies on muscles and tendons, and to a lesser degree the capsule and ligaments for stability. What surrounds the ball and socket is a sheath called the joint capsule which holds it all together. Over the top of the shoulder structure is the acromion process which forms an arch under which pass tendons and bursa sacks (fluid filled sacks which lubricate the surrounding tissue). Behind it all is the scapula, or shoulder blade which floats on the rib cage and is controlled entirely by muscle movement. Surrounding all of this are the rotator cuff, pectoralis, deltoid, biceps and triceps muscles (to name a few) which control joint motion.

At The Stone Clinic in San Francisco, the two most common acute injuries seen in windsurfing are tears of the rotator cuff and dislocations. Chronic injuries are usually impingement (pinching) of the cuff underneath the acromion. The acute injuries to the rotator cuff occur from landing hard on the shoulder often against the board. The dislocations occur when being launched forward and catching the arm behind the sailor's body. The body goes forward, the arm back, and the ligaments tear. Both of these injuries, if complete, frequently require surgical repair for full function. Again the repairs are performed as an outpatient procedure, under local anesthesia, with return to sailing at about three to four months.

The rotator cuff in particular is an area that is vulnerable to injury. It consists of a group of four muscles in the shoulder that not only rotate the arm into different positions, but also act as stabilizers to keep the ball of the ball and socket joint doing what it should be doing. An injury to this muscle group can happen suddenly with a forceful muscle contraction or as the result of a fall. It typically causes pain with movements out to the side or into rotation, an inability to lift things comfortably above shoulder height, and dull or throbbing pain at nighttime.

Following an injury to the rotator cuff, an accurate diagnosis should be made by an exam and sometimes an MRI. Ice for 15-20 minute sessions, a couple of times a day for the first 3-5 days helps to reduce swelling and pain. After that time, ice anytime the shoulder is painful, stiff or irritated. Gentle range of motion exercises are initiated to prevent loss of mobility and allow healing of the involved tissues.

Pendulum exercises are performed by leaning over and supporting your body with your uninjured arm on a table. Letting your arm hang downward, rotate your body to let the arm swing in circles--starting with small circles and increasing as comfortable. This should be performed in 20-30 repetitions in both directions, 3-5 times a day and whenever the shoulder is stiff and sore.

A mast or even mast base can also be used to stretch overhead. Grasping the end of the pole with the injured arm, use the opposite hand to lift the pole in front of you upward and overhead. Keep the shoulder relaxed and try not to let it hike up as this will cause more soreness. This should also be performed 3-5 times a day but with fewer repetitions.

Strengthening exercises should focus not only on the injured muscles in a controlled manner, but also the surrounding muscles. Each exercise should be performed with high repetitions (20-30) for a couple of sets and lighter weight to engage the slow-twitch, or endurance muscle fibers. A soup can be used as resistance initially. Once a base of muscle activity has been achieved, usually after 4-6 weeks, then the resistance can be increased as tolerated. All exercises should be done in a smooth fashion with perfect posture and without compensating by hiking your shoulders or performing them too quickly. Let the muscles do the work, not momentum. Some of the major muscle groups that should be focused on are listed below.

* Biceps curls can be performed by lifting a weight with the hand and flexing at the elbow.

* Triceps strengthening is accomplished by bending over and leaning on a chair, your arm is at your side and your elbow is bent. Straighten your arm behind you and then flex back to the starting position.

* Rhomboids are between the shoulder blades and are engaged by bending at the waist and resting your head on a towel on a counter top. Your arms should be hanging down and then bring them out to the side like your are trying to fly. Bent over rows will also isolate this muscle group.

* Rotator cuff strengthening is performed by putting a rolled up towel under your arm, keep your elbow bent 90 degrees, stand up straight and rotate your arm inward and outward.

Another common chronic injury to the shoulder in windsurfing is impingement. An impingement is the result of the soft tissue that runs underneath the acromion arch getting pinched repetitively and inflamed. Once it is inflamed, it becomes swollen. The impingement is also commonly called bursitis and/or tendinitis of the rotator cuff. Although quite different from a rotator cuff tear, chronic impingement can eventually lead to muscle tearing if not properly treated. A few predisposing factors for an impingement are poor posture, anatomical predisposition, muscle imbalance, and faulty overhead mechanics (i.e. poor lifting technique, bad position of the boom in relationship to your height). Symptoms are pain with lifting the arm out to the side--which is worse when the arm is at shoulder height, radiating pain that typically travels down the outside of the arm, and an inability to sleep on that side. There can also be sensations of weakness when trying to perform certain activities.

The treatment is similar to that of a rotator cuff injury with ice when irritated, avoidance of irritating activities, and the same strengthening exercises as listed above. A couple of other things that need to be taken into consideration are posture and stretching. Good posture with shoulders back and head up straight is imperative to decrease the pressure on the healing area. When the shoulders begin to roll forward and the head follows them, this increases the pinch on the underlying tissue. If someone is in bad posture throughout the day, every time they try to use that arm, they are impinging and potentially making the injury worse.

Stretching should focus on the chest muscles in particular. Grasp a doorjamb with your fingertips and slowly lean away from your hand until it stretches in the chest. Hold 20 seconds and repeat 3 times on each arm, 3-5 times a day. Repetitive actions should also be avoided to reduce the strain on the area. Limit the time on your board to 30-45 minutes initially so as to not overfatigue the muscles and increase the susceptibility to injury.

Cardiovascular conditioning in the form of cross-training is also essential to allow for a smooth transition back to sailing. Gym routines of cycling, spinning, or stair machines using a circuit routine (i.e. warm-up for 5 minutes, sprint for 30 seconds and then back off a little for a minute; perform sets of these with a 3 minute cool-down) is essential to maintain endurance and aid in the healing process.

Getting back to the water following shoulder injuries requires a comprehensive program of increasing intensity that focuses on strength and motion but without jeopardizing healing. Maintaining strength and integrity of the rest of the body while healing is also critical for early return to windsurfing.