Prevalence of Musculoskeletal Injuries in Competitive Paddlers at Dabulamanzi Canoe Club

o Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

o NonCommercial — You may not use the material for commercial purposes.

o ShareAlike — If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.

How to cite this thesis

Surname, Initial(s). (2012). Title of the thesis or dissertation (Doctoral Thesis / Master’s Dissertation). Johannesburg: University of Johannesburg. Available from: http://hdl.handle.net/102000/0002 (Accessed: 22 August 2017). PREVALENCE OF MUSCULOSKELETAL INJURIES IN COMPETITIVE PADDLERS AT DABULAMANZI CANOE CLUB

A dissertation submitted to the Faculty of Health Sciences, University of Johannesburg, as partial fulfilment for the requirements for the Master’s Degree in Technology, Chiropractic

Bryony Megan Rous (Student number: 201575171)

Supervisor: ______Date: ______Dr. F. Ismail DECLARATION

I, Bryony Megan Rous, declare that this dissertation is my own, unaided work. It is being submitted as partial fulfilment for the Master’s Degree in Technology, in the programme of Chiropractic, at the University of Johannesburg. It has not been submitted before for any degree or examination at any other university or technikon.

Bryony Megan Rous

On this day the 4th of the Month of July 2020.

i DEDICATION

To the most special people in my life, my parents.

I’ve written this dedication a million times, trying to convey how much I love and appreciate everything you do for me. But there aren’t enough words in the dictionary to express the depth of my love and gratitude. Thank you for giving me life and being the most amazing parents that anyone could ever ask for. You’ve loved me unconditionally and picked me up whenever I’ve fallen down. You’ve been my rock and light in the dark. You’ve taught me to reach for the stars and chase my dreams, no matter how big or small. Thank you for supporting me and giving me all the opportunities that I have had. Without you I wouldn’t be who I am or where I am today.

I love you, Mom and Dad.

iii ACKNOWLEDGEMENTS

To my supervisor, Dr Fatima Ismail, thank you for all your guidance, time and dedication. It has been an honour and a privilege to work with you.

To my statistician, Mrs Juliana van Staden, thank you for all your assistance with my survey formation and data analysis.

To Dabulamanzi Canoe Club, for their contribution to the data collection process.

To all the people who participated in the survey, your time and contribution is much appreciated, and I am extremely grateful.

To my family, friends and colleagues, for all their support and guidance.

ABSTRACT

Background The problem statement identified for this study concerns the insufficient research on the prevalence of musculoskeletal injuries in competitive paddlers at Dabulamanzi Canoe Club. Prior research done in South Africa is limited and outdated.

Aim The aim of this study was to determine the prevalence of musculoskeletal injuries in competitive paddlers at Dabulamanzi Canoe Club, with the intention of identifying whether certain body regions were more susceptible to injury in marathon kayakers, sprint kayakers or athletes who compete in both disciplines.

Methodology A cross-sectional, quantitative, exploratory descriptive study was conducted through the means of a questionnaire. The sample consisted of 205 active competitive paddlers, who were recruited randomly via email and word of mouth, at time-trials and training sessions at Dabulamanzi Canoe Club. Participants were between the ages of 18 and 50, with a 1:5 female to male ratio. The results of the survey were analysed using descriptive statistical analysis, specifically mean scores, frequencies and p-values.

Results Fifty-five active competitive paddlers completed the questionnaire (26.83% response rate) of whom 9 were female, 45 were male and 1 identified as ‘Other’. Of the sample, 72.5% (n=40) of the participants reported that they had been injured during their paddling career, however, only 23.6% (n=13) reported that they had been pre-disposed to the injury prior to commencing their paddling career. This study established that there was a higher prevalence of injuries in the shoulders (60%), lower back (50%), wrist/hands (37.5%), ankles/feet (30%), knees (25%) and elbows (22.5%). Reported injuries were muscle strains, ligamentous sprains, overuse injuries and varying degrees of fractures and dislocations.

Conclusion An analysis of the data collected through the questionnaire illustrates that there was an increased prevalence of musculoskeletal injury in competitive paddlers at Dabulamanzi Canoe Club. Further studies are needed to establish whether there is a direct link between the development of an injury in a certain body region and the kayaking sport.

Key Words: Kayaking, Dabulamanzi Canoe Club, musculoskeletal injury, cross-sectional study. v

TABLE OF CONTENTS

DECLARATION ...... i AFFIDAVIT ...... ii DEDICATION ...... iii ACKNOWLEDGEMENTS ...... iv ABSTRACT ...... v TABLE OF CONTENTS ...... vi LIST OF FIGURES ...... ix LIST OF TABLES...... x LIST OF APPENDICES ...... xiii CHAPTER ONE: INTRODUCTION ...... 1 1.1 Introduction...... 1 1.2 Aim ...... 1 1.3 Possible outcomes ...... 2 CHAPTER TWO: LITERATURE REVIEW ...... 3 2.1 Introduction...... 3 2.2 History of canoeing and kayaking ...... 3 2.3 Marathon and sprint kayakers...... 4 2.4 Musculoskeletal injuries in paddlers ...... 5 2.4.1 Effects of paddling on the human body ...... 6 2.4.2 Biomechanics of the paddling stroke ...... 8 2.4.3 Existing studies on musculoskeletal injuries in paddlers ...... 10 2.5 The musculoskeletal system...... 11 2.6 Anatomy related to the paddler ...... 12 2.7 The upper limb ...... 13 2.7.1 The glenohumeral joint...... 14 2.7.2 The rotator cuff ...... 15 2.7.3 The elbow joint ...... 16 2.7.4 Biomechanics of the elbow ...... 16 2.8 The spinal column ...... 17 2.8.1 The motion segment ...... 17 2.8.2 The lumbar spine...... 20 2.8.3 The sacroiliac joint ...... 21 2.9 The lower limb ...... 22 vi

2.9.1 The hip joint ...... 22 2.9.2 The knee joint ...... 23 2.9.3 The ankle joint...... 25 2.9.4 The foot ...... 27 CHAPTER THREE: METHODOLOGY ...... 28 3.1 Introduction...... 28 3.2 Study design ...... 28 3.3 Participant recruitment ...... 28 3.4 Inclusion criteria ...... 28 3.5 Sample selection and size...... 28 3.6 Preparation for data collection ...... 29 3.7 Questionnaire ...... 29 3.8 Questionnaire content...... 29 3.9 Data collection ...... 29 3.10 Data analysis and statistical procedure ...... 30 3.11 Ethical considerations ...... 31 3.12 Originality check ...... 32 CHAPTER FOUR: RESULTS ...... 33 4.1 Introduction...... 33 4.2 Demographic Data ...... 33 4.2.1 Gender ...... 33 4.2.2 Participants’ age ...... 34 4.3 Kayaking and competing history ...... 34 4.3.1 Kayaking experience...... 34 4.3.2 Competitive history ...... 35 4.3.3 Kayaking training ...... 36 4.4. Kayaking events ...... 38 4.5. Stability of the kayak ...... 38 4.6 Participants’ injury record ...... 39 4.6.1 Paddling injuries ...... 39 4.6.2 Comparison between participants’ age and the development of a paddling injury ...... 40 4.6.3 Comparison between participants’ paddling experience and the occurrence of a paddling injury ...... 41 4.6.4 Recorded injuries ...... 43 4.6.4.1 Head injuries ...... 43 vii

4.6.4.2 Neck injuries ...... 47 4.6.4.3 Shoulder injuries ...... 51 4.6.4.4 Elbow injuries ...... 56 4.6.4.5 Wrist and hand injuries ...... 60 4.6.4.6 Lower back injuries ...... 64 4.6.4.7 Hip and thigh injuries...... 68 4.6.4.8 Knee injuries ...... 70 4.6.4.9 Ankle and foot injuries ...... 74 4.7 Medical history ...... 78 4.8 Chiropractic treatment ...... 79 CHAPTER FIVE: DISCUSSION ...... 80 5.1 Introduction...... 80 5.2 Prevalence of musculoskeletal injuries in kayakers...... 80 5.3 Research Question 1 discussion ...... 82 5.4 Research Question 2 discussion ...... 83 5.5 Research Question 3 discussion ...... 83 5.6 Research Question 4 discussion ...... 85 5.7 Conclusion...... 85 CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS ...... 86 6.1 Introduction...... 86 6.2 Recommendations ...... 86 6.3 Recommendations for further studies ...... 87 REFERENCES ...... 88

viii

LIST OF FIGURES

Figure 1: Illustrations of the disciplines of canoeing (top) and kayaking (bottom) ...... 4 Figure 2: Stroke phases and sub-phases and defining positions: (1) paddle blade contact with water; (2) paddle blade immersion; (3) beginning of the extraction of the paddle blade from the water; and (4) paddle blade exit from the water ...... 9 Figure 3: Number of years the participants had been paddling ...... 35 Figure 4: Number of years the participants had been competitive members ...... 36

LIST OF TABLES

Table 1: Gender ratio of the particpants ...... 33 Table 2: Age range of the participants...... 34 Table 3: Number of days per week the participants trained at Emmarentia Dam ...... 36 Table 4: Number of hours per week the participants spent training and competing ...... 37 Table 5: Events the participants took part in ...... 38 Table 6: Category of events the participants competed in ...... 38 Table 7: Stability of the kayaks used by the participants ...... 39 Table 8: Number of participants injured while paddling ...... 39 Table 9: Participants’ predisposition to injury prior to their paddling career ...... 40 Table 10: Cross-tabulation between the participants’ age and whether they had been injured while paddling...... 40 Table 11: Cross-tabulation between the participants’ paddling experience and the occurrence of an injury ...... 42 Table 12: Number of participants who sustained a head injury ...... 43 Table 13: Types of head injury sustained by the participants ...... 43 Table 14: Class of water the participants were on when they sustained the head injury ...... 44 Table 15: Age of the participants who sustained a head injury ...... 44 Table 16: Participants who had recurrent head injuries...... 45 Table 17: Participants who received treatment for their head injury ...... 45 Table 18: Cross-tabulation between the category the participants competed in and the head injury46 Table 19: Number of participants who sustained a neck injury...... 47 Table 20: Types of neck injury sustained by the participants ...... 47 Table 21: Class of water the participants were on when they sustained the neck injury ...... 48 Table 22: Age of the participants who sustained a neck injury ...... 48 Table 23: Participants who had recurrent neck injuries ...... 49 Table 24: Participants who received treatment for their neck injury ...... 49 Table 25: Cross-tabulation between the category the participants competed in and the neck injury 50 Table 26: Number of participants who sustained a shoulder injury ...... 51 Table 27: Types of shoulder injury sustained by the participants ...... 51 Table 28: Class of water the participants were on when they sustained the shoulder injury...... 52 Table 29: Age of the participants who sustained a shoulder injury...... 53 Table 30: Participants who had recurrent shoulder injuries ...... 53 Table 31: Participants who received treatment for their shoulder injury ...... 54 x

Table 32: Cross-tabulation between the category the participants competed in and the shoulder injury ...... 55 Table 33: Number of participants who sustained an elbow injury ...... 56 Table 34: Types of elbow injury sustained by the participants ...... 56 Table 35: Class of waterbody the participants were on when they sustained the elbow injury ...... 57 Table 36: Age of the participants who sustained an elbow injury ...... 57 Table 37: Participants who had recurrent elbow injuries ...... 58 Table 38: Participants who received treatment for their elbow injury ...... 58 Table 39: Cross-tabulation between the category the participants competed in and the elbow injury ...... 59 Table 40: Number of participants who sustained a wrist or hand injury ...... 60 Table 41: Types of wrist or hand injury that the participants sustained ...... 60 Table 42: Class of water the participants were on when they sustained the wrist or hand injury ..... 61 Table 43: Age of the participants who sustained a wrist or hand injury ...... 61 Table 44: Participants who had recurrent wrist or hand injuries ...... 62 Table 45: Participants who received treatment for their hand or wrist injury ...... 62 Table 46: Cross-tabulation between the category the participants competed in and the wrist or hand injury ...... 63 Table 47: Number of participants who sustained a lower back injury ...... 64 Table 48: Types of lower back injury that the participants sustained ...... 64 Table 49: Class of water the participants were on when they sustained the lower back injury...... 65 Table 50: Age of the participants who sustained a lower back injury ...... 65 Table 51: Participants who had recurrent lower back injuries ...... 66 Table 52: Participants who received treatment for their lower back injury ...... 66 Table 53: Cross-tabulation between the category the participants competed in and the lower back injury ...... 67 Table 54: Number of participants who sustained a hip or thigh injury ...... 68 Table 55: Types of hip or thigh injuries that the participants sustained...... 68 Table 56: Cross-tabulation between the category the participants competed in and the hip or thigh injury ...... 69 Table 57: Number of participants who sustained a knee injury...... 70 Table 58: Types of knee injury that the participants sustained ...... 70 Table 59: Class of water the participants were on when they sustained the knee injury ...... 71 Table 60: Age of the participants who sustained a knee injury ...... 71 Table 61: Participants who sustained recurrent knee injuries ...... 72 xi

Table 62: Participants who received treatment for their knee injury ...... 72 Table 63: Cross-tabulation between the category the participants competed in and the knee injury 73 Table 64: Number of participants who sustained an ankle or foot injury ...... 74 Table 65: Types of ankle or foot injuries that the participants sustained ...... 74 Table 66: Class of water the participants were on when they sustained the ankle or foot injury ...... 75 Table 67: Age of the participants who sustained an ankle or foot injury...... 75 Table 68: Participants who had recurrent ankle or foot injuries...... 76 Table 69: Participants who received treatment for their ankle or foot injury ...... 76 Table 70: Cross-tabulation between the category the participants competed in and the ankle or foot injury ...... 77 Table 71: Participants who had a chronic medical condition ...... 78 Table 72: Types of chronic medical conditions that the participants had ...... 78 Table 73: Participants with a chronic medical condition who were receiving treatment...... 79 Table 74: Participants who had previously received chiropractic treatment ...... 79 Table 75: Participants who would consider seeing a chiropractor...... 79 Table 76: Comparison of results from similar studies ...... 81

xii

LIST OF APPENDICES

Appendix A: Permission Letter from Dabulamanzi Canoe Club ...... 94 Appendix B: Ethical Clearance Letter...... 95 Appendix C: Higher Degrees Committee Permission Letter ...... 97 Appendix D: Adapted Musculoskeletal Questionnaire...... 98 Appendix E: Information Letter ...... 106 Appendix F: Consent Form ...... 110 Appendix G: Statistician Agreement Letter ...... 111 Appendix H: Turnitin Originality Report ...... 112

xiii

CHAPTER ONE: INTRODUCTION

1.1 Introduction Kayaking has become an extremely popular sport in South Africa, with events taking place in a wide range of waterbodies across the country. This sport involves athletes racing their kayaks from one point to another, either over flat water or through rapids and waves. Research has been published about the musculoskeletal disorders affecting outreach paddlers in Hawaii, however, there is only limited research on paddlers in South Africa. This study hopes to provide a greater awareness of the musculoskeletal injuries affecting competitive paddlers at Dabulamanzi Canoe Club.

In 1979, the Dabulamanzi Canoe Club was established in Johannesburg. The founding members of this club appreciated that the Emmarentia Dam would become a sought-after venue for future paddling generations. Today, this club hosts approximately 1000 members. These members include world champions in various categories, South African national team members, South African champions, a strong provincial representation as well as recreational paddlers (Dabulamanzi Canoe Club, 2020).

According to the American Heritage Dictionary of the English Language (2016), a paddler can be defined as someone paddling a canoe, kayak or watercraft. Any reference made to the term ‘paddler’ in this study will be in reference to kayakers. Kayaking is divided into two disciplines − sprinting and marathon kayaking. These two disciplines will be further discussed in the following chapters.

1.2 Aim The aim of this study was to determine the prevalence of musculoskeletal injuries in competitive paddlers at Dabulamanzi Canoe Club, with the intention of identifying whether certain body regions were more susceptible to injury in marathon kayakers, sprint kayakers or athletes who compete in both disciplines. Dabulamanzi Canoe Club was chosen for this study due to the large number of kayakers who are registered active members.

From the aim above, the following research questions were identified: 1. Does paddling increase the prevalence of musculoskeletal injury development? 2. Is there an increase in the prevalence of musculoskeletal injuries in competitive paddlers who have been competing for a longer period of time? 3. Is there a higher prevalence of musculoskeletal injuries in certain body regions compared to others? 4. Are certain body regions more susceptible to injury in paddlers who compete in marathons, sprinting or both disciplines? 1

1.3 Possible outcomes Possible outcomes may determine the prevalence of musculoskeletal injuries that occur in the paddlers at Dabulamanzi Canoe Club. Further outcomes may determine the musculoskeletal injuries that occur in the different kayaking disciplines. Information can be documented to indicate whether these different disciplines of kayakers develop similar injuries or if there is a higher prevalence of marathon athletes with traumatic injuries due to their portage1 through rough, turbulent water.

1 According to the International Canoe Federation a portage requires the athlete to disembark from their watercraft, run a short distance to a different entry point on the waterbody. 2

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction This study was concerned with the kayakers at Dabulamanzi Canoe Club, with a primary focus on the incidence of musculoskeletal injuries affecting paddlers at the Club. The research identified and documented the prevalence as well as the types of injury that occurred in the paddlers. The secondary focus of the study was to differentiate between the types of injury that occurred in the different categories of kayakers. Over the course of the literature review presented in this chapter, broader topics relating to the biomechanics of the paddling stroke and the related musculoskeletal injuries will be discussed to give the reader further insights into the injuries that paddlers are susceptible to. Further discussion will be focused on the relevant anatomical structures that are predominantly injured in this sport.

2.2 History of canoeing and kayaking Watercrafts have been in existence for centuries. Where there was a body of water, there was an indigenous watercraft that accompanied it. These watercrafts were primarily in the shape of a canoe. These canoes were primitive yet elegantly constructed and could range from 3 metres to over 30 metres in length. Throughout history, these watercrafts have been made from logs, animal skins and tree bark. Canoes were used as a mode of transport, as well as for trade and warfare. The original design of the watercraft depended on its function and the region it was built in. Theses crafts varied between open-topped bark canoes, a dug-out tree canoe or 39.6 metre war canoes. Canoes were used on a wide scale, ranging from native American tribes to the Polynesians (International Canoe Federation, 2018).

Kayaks were built primarily to transport single persons and were used for hunting and fishing. These watercrafts were built in such a way to prevent icy Arctic water from entering the cockpit. This was accomplished by stretching animal skins over a wooden frame. Kayak (ki ak) is an Eskimo word for ‘man- boat’, which was predominantly found in North America, Siberia and Greenland (International Canoe Federation, 2018).

Kayaks and canoes differ physically since kayaks are closed watercrafts in which the paddler is seated and uses an offset double-bladed paddle. Canoes, on the other hand, are open watercrafts that are paddled from a lunging or kneeling position with a single-blade paddle (International Canoe Federation, 2018).

Figure 1: Illustrations of the disciplines of canoeing (top) and kayaking (bottom)

(von Braun, Frenzel, Kding & Fuchs, 2020).

Today, canoeing and kayaking events take place all over the world, with the sport being recognised by the Olympic Games. The two different watercrafts shown in Figure 2.1 above are used by athletes in two separate disciplines and are distinguished by the use of the initial letter C (Canoe) and K (Kayak). Even though athletes compete in two different events using different watercrafts, the sport in its entirety is referred to as ‘canoeing’ (Olympic Games, 2020).

Since this study is focused on the kayaking sub-division of canoeing, any further reference made to this sport will be done using the term ‘kayaking’ to ensure that there are no misunderstandings.

2.3 Marathon and sprint kayakers A kayak marathon involves athletes racing their kayaks from one point to another across possible combinations of rivers, lakes, estuaries and seas. Competitors may have to navigate around obstacles and carry their boat at times if necessary. Marathons are generally raced standard distances of up to 100km (Cryer, 2014). River difficulty is rated internationally on a scale of Class 0 to Class 6. The river classes are classified as follows (Gauteng Canoe Union - GCU, 2014): • Class 0 – Flat stationary water • Class 1 – Moving water with small waves • Class 2 – Easy rapids with waves up to a metre high • Class 3 – Rapids with high irregular waves • Class 4 – Long difficult rapids with constricted passages • Class 5 – Extremely difficult, long and very violent rapids 4

• Class 6 – For teams of experts only

Marathon kayakers may also compete on flat water surfaces. This discipline is highly tactical and takes place in a lap format, with a portage at the end of every lap. Portage requires the paddlers to get out of their boats and run a short distance to a different entry point (Fisher, 2015). Different distances are raced depending on the age category and the gender of participants (GCU, c2014). South African marathon championship distances (International Canoe Federation, 2018) are: • Junior men: 5 laps, 21km • Junior women: 4 laps, 17km • Senior and under 23 men: 7 laps, 30km • Senior and under 23 women: 6 laps, 25km

In kayak sprint events, athletes race on a straight course, with each boat in a separate lane, over different distances. These distances are: 200 metres, 500 metres, 1000 metres and 5000 metres. The athletes can also compete in a 200-metre x 4 relay (GCU, 2014).

2.4 Musculoskeletal injuries in paddlers Kayaking in South Africa has grown over the years and has become a popular competitive sport (Canoeing South Africa, 2020). The kayaking motion is incredibly complex and requires repetitive motions of the upper limbs in combination with the trunk and lower extremities. It is imperative to understand the mechanics that are associated with performing this action to have a thorough understanding of the manner in which injuries may occur. Research indicates that kayakers can take up to eight thousand paddle strokes in a two-hour distance race. As a result, it is important to understand the upper extremity kinematics associated with the kayak forward paddle stroke. Wassinger (2007) states that kayakers are susceptible to many orthopaedic injuries in the shoulder. These injuries may include subacromial impingement, rotator cuff tendonitis, bursitis and biceps tendonitis. The development of these injuries may be linked to faulty kinematics, particularly pertaining to asymmetry which may contribute to overuse injuries seen in kayakers’ shoulders (Wassinger, 2007).

Despite the growth of this sport, there is little documented research on the effects kayaking has on the human body (Haley & Nichols, 2009). Determining which musculoskeletal injuries occur more frequently in this sport would allow appropriate preventative measures to be put into place.

2.4.1 Effects of paddling on the human body Kayaking involves the paddler being seated in the kayak, facing the direction of motion. The paddler uses a double-bladed shaft to propel the boat through the water by performing strokes on alternative sides of the boat. The kayak has a rudder for steering, which is controlled by pedals at the front of the boat by the paddler’s feet. Both sprint and marathon kayakers are seated in their watercraft with a ‘sprayskirt’ around their waist which prevents water from entering the cockpit (Canoeing South Africa, 2012). A ‘sprayskirt’ is more commonly used by marathon kayakers as they are more likely to be exposed to rough turbulent water. A ‘sprayskirt’ may also allow the athletes to do an ‘Eskimo roll’ (Altfather & Peterson, 2012). An Eskimo roll is a self-rescue technique when a boat capsizes. To execute this technique, the capsized paddler remains in the kayak and re-rights the boat with body movement, or more commonly, with body movement aided by the use of the paddle. An Eskimo roll is difficult to learn and must be practised regularly to be reliable (Altfather & Peterson, 2012). By executing this roll, the athletes can save time during the race rather than pulling on the draw-cord and exiting the boat. If the kayak capsizes and the kayaker cannot perform an Eskimo roll to re-right the craft, then the kayaker can pull on the draw-cord to perform a ‘wet exit’ (Fiore & Houston, 2001). Athletes who cannot perform this roll may perform other self-rescue techniques such as the ‘Cowboy’, the ‘Paddle Float’ and the ‘Re-enter and Roll’ (with Paddle Float) (Altfather & Peterson, 2012).

When the kayaker uses the Cowboy technique to re-right the boat, the kayaker will pull himself onto the stern of the boat and swing around to straddle the kayak with a leg on each side. The kayaker will then work his way forward until he can lower his buttocks into the seat and pull his legs into the cockpit. This technique can be time consuming as it requires agility, balance and flexibility. This technique can be difficult to perform in a narrow boat, especially those with small cockpits, and in high winds or rough water (Altfather & Peterson, 2012).

The Paddle Float technique is the most commonly used method to re-right a capsized boat. A paddle float is either an inflatable bladder, a foam bead-filled bag or a rigid foam bag. This aid is slipped over or connected to one of the paddle blades. To perform this technique, the capsized kayaker performs a wet exit by releasing the sprayskirt and pushing himself out of the overturned boat. The kayaker then re-rights the boat, extracts the paddle float from its place and slips it over the paddle blade. The paddle float is then inflated by blowing into an inflation tube until the bag is substantially full and then the valve is closed. When inflated, this aid typically produces about 6.8 kilogrammes of buoyance. The kayaker, still swimming or floating beside the kayak, then positions the paddle over the rear deck of the upright kayak and at 90 degrees to the keel line (Altfather & Peterson, 2012). In this position, the paddle float acts as an outrigger to stabilise the kayak as the kayaker pulls himself up and onto the rear deck and hooks a leg over the extended paddle shaft. At this point, the kayaker is face down over the boat. The kayaker then turns his head towards the front of the boat 6

and moves both legs over the paddle shaft and into the cockpit. The kayaker then swivels himself into an upright position and lowers his buttocks into the seat. The excess water needs to be pumped out of the cockpit area using a hand-held, manual bilge pump built into the boat. Once the paddler is safely back in the boat, the paddle float is removed from the paddle blade and stowed in the boat. The sprayskirt is reattached and the kayaker can resume paddling. This technique requires strength, agility and balance. The paddle float only resists capsizing in the direction towards the float and does little or nothing to avoid capsize in the opposite direction (Altfather & Peterson, 2012).

The Cowboy and the Paddle Float are two alternative self-rescue techniques which can be time-consuming and require a large amount of skill to execute. If the paddler is inexperienced, they should rather perform a wet exit out of the boat and swim to shore where they can enter the boat more safely (Canoeing South Africa, 2012). The athlete may also opt to avoid difficult obstacles by doing a portage and re-entering the waterbody further down the course. All these factors have an effect on the paddler’s body, however, none of these factors has the same effect on the athlete’s performance as the paddling stroke.

The paddling stroke is very complex and if not performed correctly, can result in multiple muscle strains, inflammatory conditions and ligamentous sprains (Jean-Baptiste, 2009). The torso and lower extremities, in combination with the upper extremities, are used to execute the paddling stroke by applying a force to the paddle. If the paddling stroke is not performed correctly, then a sudden unexpected force against the paddle can result in stress to the upper extremities, particularly the shoulder girdle (Fiore & Houston, 2001).

The paddling stroke exerts stress on the competitor’s forearms, shoulders and back muscles. Research suggests that tenosynovitis of the wrist extensors occurs in endurance paddlers (Du Toit, Sole, Bowerbank & Noakes, 1999). Paddlers use these muscles for multiple hours at a time, which may result in the muscles becoming fatigued and overused. The pull phase during the paddling stroke puts large amounts of stress on the rotator cuff muscles, but there is no supporting evidence to suggest whether musculoskeletal injuries are more prevalent in this area (Du Toit et al., 1999). However, the data obtained from the study of Du Toit et al. (1999) is now outdated and may not apply to today’s competitive athletes.

Injury in paddlers generally occurs due to an altered paddling style. This may occur during difficult paddling conditions, such as choppy water. Injuries do not appear to be related to the equipment used by the individual athletes. However, numerous factors can affect the paddling style, such as fitness level and the ability to stabilise an unstable kayak, thereby maintaining optimum paddling style without repeated eccentric loading of the forearm tendons to limit hyperextension of the wrist (Haley & Nichols, 2009).

2.4.2 Biomechanics of the paddling stroke The ability to generate propulsion and minimise drag is crucial for success in sprint kayaking. The kayaking technique is a recurrent movement composed of alternate left and right strokes. The stroke cycle is the sum of a left and a right stroke. Each stroke includes two phases: the water phase and the aerial phase. The water phase occurs from the entry of the paddle blade into the water to its extraction. The aerial phase takes place from blade exit to the resubmission of the blade on the contralateral side of the boat (Gomes, 2015).

The water phase is further divided into sub-phases. These sub-phases include the entry, pull and exit. To initiate the stroke, the paddle enters the water. To allow the paddle blade to enter the water, the draw shoulder is in front of the thrust shoulder, which causes the torso to rotate away from the side of paddle entry. The elbow of the draw arm is fully extended while the shoulder is flexed. This positioning allows the paddle blade to be placed in the water as far toward the front of the boat as possible. When the thrust shoulder is abducted, the elbow is simultaneously flexed to facilitate forward entry of the paddle blade (Gomes, 2015).

During the entry sub-phase is when catch occurs. This is the moment which signifies the onset of propulsive forces. This results in the propulsive forces overcoming the resistive forces, which leads to the acceleration of the kayak. The catch should occur as soon as possible during the entry phase. This sub-phase ends when the blade is completely submerged and locked into position (Gomes, 2015).

The paddle stroke will then continue to the pull sub-phase. During this sub-phase the blade should be stationary in the water. The effect of blade slip is initiated when the force exerted to the paddle exceeds the resistance on the blade in the water; this dissipates power by imparting kinetic energy to the water. The blade is then moved posteriorly and laterally until it passes the kayak seat and starts to exit the water. It is in the pull sub-phase when the blade is in a vertical position and its surface area is maximised. The drag forces which act perpendicular to the blade contribute more to the kayak’s longitudinal propulsion. In the pull sub- phase, the draw knee and hip are extended during paddle movement in the water to help drive the draw hip backwards, producing rotation of the torso. This movement is combined with movement in the transverse plane of the shoulder girdle, thoracic and lumbar spines and the pelvic girdle. The exit sub-phase starts with the blade exiting the water as cleanly as possible, in combination with the rising of the thrust hand (Gomes, 2015).

During the aerial phase the thrust hand continues to rise superiorly to the shoulder and is then pushed to full extension of the arm, in combination with a little crossing over the athlete’s face to the contralateral side (Gomes, 2015).

Researchers have hypothesised that the most effective stroke force profile would be one in which the peak propulsive force was large and quickly achieved. Thus, maintaining near peak for as long as possible, and then reduced to zero as quickly as possible (Gomes, 2015).

Figure 2: Stroke phases and sub-phases and defining positions: (1) paddle blade contact with water; (2) paddle blade immersion; (3) beginning of the extraction of the paddle blade from the water; and (4) paddle blade exit from the water (Gomes, 2015)

The paddling stroke technique not only uses arm movements, but also utilises the trunk and legs. Previous research has indicated that more body parts and muscle groups are recruited as the athletes hone their paddling technique. This view is supported by Brown, Lauder and Dyson (2010), who maintain that the paddling force produced by elite paddlers has important contributing factors from the trunk and lower limbs. This requires a very complex coordination and synchronisation process between the different segments (Gomes, 2015). This is considered the correct kayaking technique; as a result, any alteration to this technique may lead to injury due to altered biomechanics. Individuals tend to make the following mistakes when performing the paddling stroke - the lack of push phase and a weak or non-contributory torso rotation (Wassinger, 2007).

The forward stroke is used to propel the kayak in a straight trajectory. This stroke is accomplished using a symmetrical bilateral motion. In healthy kayakers, there will be a difference when comparing strokes bilaterally, but this is considered to be a fairly normal finding. The double-bladed paddles are offset to varying degrees. Athletes who take part in competitive events use a standard paddle that is offset by 90 degrees. Motion of the upper extremities is used to place the offset blade into the water. This motion has been hypothesised to be a contributing factor to the bilateral asymmetry found in paddlers. To immerse the blade in the water, a ‘control’ hand and an ‘off’ hand are required to perform the motion and to change the paddle

blade positioning. The control hand maintains the grip on the paddle shaft during the entire stroke, while the ‘off’ hand loosens the grip to allow rotation of the paddle for proper blade placement in the water (Wassinger, 2007).

2.4.3 Existing studies on musculoskeletal injuries in paddlers Haley and Nichols (2009) stated that the shoulder and the back were the most common sites of injury, however, they did not specify what the specific musculoskeletal injuries to these areas were. As a result, further investigation is warranted.

Du Toit et al. (1999) investigated the incidence and causes of acute tenosynovitis of the forearm in marathon kayakers. Their study is now over 20 years old and is therefore outdated given the rapidly evolving technological advances in this sport. Du Toit’s study found that 23% of the competitors in each race developed tenosynovitis of the wrist extensors. The development of this injury was significantly higher in the athletes’ dominant hand compared to the non-dominant hand. The study reported that the injury was not related to the type of kayak used or the angle of the paddle blades. It was documented that kayakers who covered more than 100km a week for eight weeks preceding the race had a significantly lower incidence of tenosynovitis than those who trained less. Environmental conditions, including turbulent water and high wind conditions, as well as the paddling technique − especially hyper-extension of the wrist during the pushing phase of the stroke − were both related to the incidence of tenosynovitis. Competitive conditions are categorised according to the difficulty of the water surface and the competition conditions (Du Toit et al., 1999).

Krupnick, Cox and Summers (1998) revealed that the most frequently reported injuries were ligamentous sprains, tendonitis and chronic musculoskeletal pain. Other conditions that were recorded included simple bruises, infections, dislocations and lacerations. This study was done to determine the occurrence and nature of injuries associated with the various elements of whitewater paddling in order to assist with medical resource planning at competitive events. This study is also dated and is, in any case, concentrated on whitewater paddling which requires the athlete to kneel in the boat and use a single shafted blade in the paddler’s dominant hand. This kayaking method is different to the one that is being examined in this study, moreover, the research was conducted in a different country.

Fiore’s (2003) study on the injuries associated with whitewater rafting and kayaking revealed that even though these extreme sports are undergoing substantial growth, they carry severe risks. Rafting and kayaking injuries appear to result from different mechanisms, with most of the raft injuries occurring from contact with equipment on the raft. In contrast, most kayakers suffer injuries due to contact with objects in the water and 10

the stress of the water on the kayaker’s equipment. Lacerations were reported in both groups although shoulder injuries were more prevalent in the kayakers.

An earlier study conducted in 2001 by Fiore and Houston sought to gather epidemiological data on whitewater kayaking injuries worldwide. Most of the injuries that occurred were reported to have occurred while the paddler was still in the watercraft. The most common mechanism of injury was striking an object in the water, followed by traumatic stress and overuse. The study revealed that the most common injuries were abrasions (25%), tendinitis (25%), contusions (22%) and dislocations (17%). Moreover, the body region that was primarily injured was the upper extremity, especially the shoulder. Fiore and Houston (2001) concluded that the development of injuries was most likely connected with the number of days a year that the sport was pursued. The kayakers reported injuries predominantly on rivers that were assessed to be at a level appropriate to their skills.

Viviers (2006) investigated whether there was a relationship between paddle grip and the development of lateral elbow tendinosis and de Quervain’s tenosynovitis in K1 marathon paddlers at the 2006 Isuzu Berg River Canoe Marathon in South Africa. This study revealed that the incidence of lateral elbow tendinosis and de Quervain’s tenosynovitis was 11.81%. There were no significant findings to demonstrate whether there was a correlation between paddle grip and the development of these conditions. This study indicated that a possible factor contributing to the development of lateral elbow tendinosis and de Quervain’s tenosynovitis included training frequency in preparation for the kayak marathon and time-trial performances.

Feher (2009) investigated the incidence of injuries sustained by kayakers during the 2006 Isuzu Berg River Canoe Marathon in South Africa. This study used 57 male kayakers who qualified to compete in the race and were registered for the marathon. The findings revealed that kayakers who participated in long distance multi- stage events appeared to be at a higher risk of sustaining soft tissue injuries. The younger kayakers appeared to be at greater risk of muscle strains, which may have been provoked by weightlifting training exercises. The most commonly reported injuries were in the hands (25%), the shoulder girdle (17.1%) and the lumbar spine (11.4%). The most prevalent injuries were muscle strains (30%), blisters (25%) and muscle cramps (20%).

2.5 The musculoskeletal system The musculoskeletal system, with the aid of the Central Nervous System, provides two basic physical functions. These functions include mobility and the performance of everyday activities. These functions may be hampered by any muscular weakness or joint and bone stiffness as a result of immobility or disuse. The weakened system may be more prone to the development of injuries and infection (Nigam, Knight & Jones, 2009). 11

Voluntary skeletal muscle consists mainly of slow twitch fibres (Type I) and fast twitch fibres (Type II).

Slow twitch fibres (Type I) contract slowly and produce large amounts of energy to sustain the body for longer periods of time. They contain large amounts of myoglobin (which stores oxygen) and have numerous capillaries and mitochondria which assist these fibres with fatigue resistance. These fibres are predominantly found in the muscles of the neck and back, which maintain the upright bipedal posture. They play an essential role in endurance activities, such as long-distance running. To execute this role, the fibres are found in abundance in the soleus muscle of the lower limb (Nigam et al., 2009).

Fast twitch fibres (Type II) contract quickly but fatigue rapidly. They contain little myoglobin and relatively few mitochondria. These fibres adapt to perform rapid movement but consume large amounts of energy as they cannot generate enough energy for a continuous supply of adenosine triphosphate (ATP). Upper limb musculature contains numerous fast twitch fibres (Nigam et al., 2009).

The primary function of bone is to provide mechanical support for the body, tissues and muscles. This structure also maintains mineral homeostasis by providing a reservoir of calcium, phosphorus and magnesium salts. The hard matrix of bone contains the calcium and phosphorus reserves which are present as hydroxyapatite crystals. The mechanical stresses on the bone control and influence the deposition and orientation of the hydroxyapatite crystals. A reduction in mineral content in bone tissue has been noted in individuals who have little force acting on their body for any length of time. This leads to a decrease in bone density and consequently a reduction in strength (Nigam et al., 2009).

2.6 Anatomy related to the paddler Kayaking is both a physically and physiologically demanding sport. In addition to maintaining substantial fitness levels, the correct technique during each phase of the paddling stroke is important for achieving optimal performance. Biomechanical dysfunction, injury and/or pain as well as incorrect technique are the most common reasons for a decrease in power output, thereby resulting in compromised paddling performance. This can be related to dysfunction in the upper limb, especially the rotator cuff, and the lumbar spine.

The kayaking technique is a recurrent movement composed of alternate left and right strokes. The stroke cycle is the sum of a left and a right stroke. The kayaking technique is a very complex motion and requires multiple joints and muscle groups to work together to propel the boat through the body of water. The paddling stroke technique not only uses arm movements, but also utilises the trunk and legs. Past research has shown that as skill increases, more body parts and muscle groups are recruited. This is supported by Brown et al. 12

(2010) who indicated that the trunk and lower limbs play an important role in paddling force production among elite paddlers. This requires a very complex coordination and synchronisation process between the different segments (Gomes, 2015).

Each stroke is accomplished with the use of the upper limb, namely, the glenohumeral joint, rotator cuff, elbow joint and forearm muscles. To allow the paddle blade to be immersed into the water on alternative sides of the boat, the trunk and lower limbs rotate. The rotation of the trunk is contralateral to that of the upper limbs. This allows the paddle blade to be immersed in the water as far forward as possible. This will maximise the time of the blade in the water and will propel with boat forward at a faster rate.

During the kayaking motion, the lower limb contralateral to the immersed blade is bent while the ipsilateral lower limb extends. As a result, the lower limbs show pedalling motions throughout the kayaking cycle (Begon, Colloud & Sardain, 2010). The lower limbs will also be utilised when the paddler opts for portage, running to the next input site.

This is considered the proper technique for kayaking. Any alteration to this technique is deemed inadequate and will lead to biomechanical issues. Research has shown that common errors made while performing the kayaking stroke include the lack of push phase and a weak or non-contributory torso rotation (Wassinger, 2007).

In conclusion, the main structures utilised to propel the boat through the water include the upper limb (glenohumeral joint, rotator cuff and elbow joint), the spinal column (lumbar spine and sacroiliac joint) and the lower limb (hip joint, knee joint, ankle and foot). These structures will be discussed in further detail below.

2.7 The upper limb The upper limb plays a vital role in the forward propulsion of the kayak. The thrust shoulder is abducted while the thrust elbow is flexed simultaneously to facilitate forward paddle entry. The further forward the paddle is immersed into the water, the more this will contribute to the longitudinal propulsion of the kayak. Faulty biomechanics or a sudden force on the paddle blade could result in the development of injuries in any of the upper limb structures.

The upper limb is divided into two parts: the shoulder gridle and the arm. The shoulder girdle consists of the clavicle and the scapula. The clavicle lies proximal to the first rib and sets the boundary between the neck and the chest. The scapula is a wide, flat, triangular bone located posteriorly on the chest. The shoulder girdle is also integrated with the axial skeleton through the sternoclavicular joint. The arm compromises the 13

humerus, ulna, radius and eight carpal bones of the wrist, five metacarpal bones and 14 phalanges in the fingers (Jaworski, Karpinski & Dobrowolska, 2016).

The upper limb plays an important role in everyday activities. These include communication and expression of emotions. The upper limb is a complex structure that allows a series of movements to be performed and has 30 degrees of freedom. Movements include grasping, touching, lifting, rotating and relocating held objects. A complex system of muscles and sensory receptors is responsible for the accuracy of each movement (Jaworski et al., 2016).

2.7.1 The glenohumeral joint Extreme ranges of motion are available at the glenohumeral joint. The mobility of this joint is related to its configuration and the discrepancy between the articular surfaces of the ball-shaped humeral head and the shallow glenoid cavity. Although the configuration of this joint allows it to attain extreme ranges of motion, it also contributes to an instability factor that comes in to play. To counter the instability, additional elements are required. These elements can be divided into static and dynamic stabilisers. The relative stabilising effect of these elements varies according to the position of the shoulder, thus forming a complex biomechanical balance (Omoumi, Teixeira, Lecouvet & Chung, 2010).

Static stabilisers of the shoulder include the glenoid fossa, the coracoaromial roof and the capsulo-labral- ligamentous complex. These stabilisers are activated at extreme ranges of motion.

The glenoid labrum is a fibrocartilaginous structure which is attached to the rim of the glenoid cavity. The function of this structure is to increase the surface area and depth of the glenoid fossa to increase congruity between the two articulating surfaces of the glenohumeral joint. By increasing congruency between the two articulating surfaces, a vacuum mechanism is created. This mechanism assists to keep the humeral head in position as it moves. The glenoid labrum also serves as an attachment point for other stabilisers of the joint. These structures include the glenohumeral ligament, the biceps tendon and the capsule (Omoumi et al., 2010).

The coracohumeral ligament is a broad band extending from the lateral border of the coracoid process to the greater tubercle of the humerus, blending with the supraspinatus tendon. This ligament reinforces the upper portion of the capsule and stabilises the intra-articular portion of the bicipital tendon in conjunction with the superior glenohumeral ligament in the rotator cuff interval (Omoumi et al., 2010). The glenohumeral ligaments blend with the glenohumeral joint capsule, forming thick infoldings. These ligaments include the superior glenohumeral ligament (SGHL), the middle glenohumeral ligament (MGHL) 14

and the inferior glenohumeral ligament (IGHL). The SGHL extends from the superior aspect of the glenoid rim, near the base of the coracoid process, to a small depression superior to the lesser tubercle of the humerus. The SGHL may merge with the bicipital tendon or the MGHL. The MGHL extends from the medial edge of the glenoid rim, at the anterior superior aspect of the glenoid labrum, to the inferior portion of the lesser tubercle of the humerus. This ligament may merge with the subscapularis tendon. The IGHL is formed by a complex which consists of two bands and the axillary recess. The anterior and posterior bands run from the glenoid labrum to the anatomical neck of the humerus (Omoumi et al., 2010).

Dynamic stabilisation is achieved by the surrounding soft tissue structures. This stabilisation can respond and adapt to changing positions and loads placed upon the glenohumeral joint during everyday activities. The primary stabiliser of the glenohumeral joint is the rotator cuff. Contraction of the rotator cuff generates a compression force between the glenoid fossa and the humeral head which establishes a fulcrum around which the major shoulder muscles act to power the movement (Hawkes, Alizadehkhaiyat, Fisher, Kemp, Roebuck & Frostick, 2011).

2.7.2 The rotator cuff The rotator cuff consists of tendons of the subscapularis, supraspinatus, infraspinatus and teres minor muscles (Van der Meijden, Westgard, Chandler, Gaskill, Kokmeyer & Millett, 2012).

The rotator cuff functions primarily to initiate joint abduction, provide internal and external rotation, and secondarily, it contributes to the dynamic stability of the glenohumeral joint (Van der Meijden et al., 2012).

The coupled force vectors of the subscapularis and teres minor muscles contribute to the depression of the humeral head in the glenoid cavity. This provides dynamic stability to the glenohumeral joint and prevents impingement of the humeral head with the acromion during deltoid activation. The secondary function of this couple is to prevent the superior translation of the humeral head after a rotator cuff tear. Contrary to the rotator cuff tendon’s ability to tolerate up to 100 N/mm of tensile strength, the tendon’s endurance of compressive and shear forces is much less (Van der Meijden et al., 2012).

The scapula plays an important role in glenohumeral joint function by providing a stable base for muscle activation and load transfer within the kinematic chain. Altered scapula positioning has been termed scapular dyskinesia. This can affect the integrity of the rotator cuff. The subacromial bursa is rich in nerve fibres. As a result, irritation and inflammation of this structure can lead to pain inhibition of the rotator cuff (Van der Meijden et al., 2012).

2.7.3 The elbow joint The elbow joint is a synovial hinge joint. It has three joints that make up its entirety − the ulnohumeral, the radiocapitellar and the proximal radioulnar joints. The ulnohumeral joint consists of the articulation of the ulnar trochlear notch with the central waist of the humeral trochlea. The radiocapitellar joint consists of the articulation of the convex cartilage-covered capitellum with the concave surface of the radial head. The proximal radioulnar joint consists of the articulation of the radial head and the coracoid process of the ulna (Tarnita, Boborelu, Popa, Tarnita & Rusu, 2010).

There are two ligamentous structures that strengthen and support the elbow joint. These structures are assisted by the surrounding musculature. These ligaments include the radial collateral ligament and the ulnar collateral ligament. The radial collateral ligament functions primarily to prevent excessive adduction of the elbow joint, whereas the ulnar collateral ligament prevents excessive abduction of the elbow joint (Tarnita, Boborelu, Popa, Tarnita & Rusu, 2010).

2.7.4 Biomechanics of the elbow The elbow is a trochoginglymus joint with three articulations that act as a link between the shoulder and the hand. This joint has two degrees of freedom − flexion-extension and pronation-supination (Martin & Sanchez, 2013).

Elbow flexion normally ranges from 0 degrees to approximately 150 degrees. The radiocapitellar joint and the proximal radioulnar joint provide 85 degrees of supination and 75 degrees of pronation. The axis passes through the centre of the radial head and extends through the radial border of the distal ulna. There are 3 to 41 degrees of varus-valgus and axial laxity that occur with elbow flexion. Hyperextension of the elbow joint is limited by impaction of the olecranon into the olecranon fossa, anterior capsule and ligaments, as well as tension in the flexor muscles. Maximal flexion is limited by the anterior muscle bulk, the impaction of the radial head and the coracoid process into their corresponding fossa, and triceps muscle tightness. The elbow in full extension and supination has a relative valgus alignment called the carrying angle. This angle measures approximately 10 to 15 degrees in men and is approximately 5 degrees greater in women (Martin & Sanchez, 2013).

The stability of the elbow joint is maintained by the bony articulations, the joint capsule and the ligamentous complexes. The ulnohumeral joint is the primary stabiliser against varus instability, whereas the medial collateral ligament provides stability against valgus stressors (Martin & Sanchez, 2013).

The elbow is utilised in various activities, and as a result, this joint is readily injured. Commonly occurring injuries are due to overuse, however, traumatic injuries have also been documented (Martin & Sanchez, 2013). 2.8 The spinal column The most important anatomical and functional axis in the human body is known as the vertebral column. It consists of seven cervical vertebrae, twelve thoracic vertebrae and five lumbar vertebrae. This structure is limited superiorly by the skull and inferiorly by the sacrum. The sacrum is a wedge-shaped bony structure which consists of five fused sacral vertebrae. Distal to the sacrum is the coccyx which is also formed by the fusion of four coccygeal vertebrae. Both the sacrum and coccyx no longer contain motion segments (Gharries, 2018).

The spinal column is an S-shaped curve. This curvature is formed by the lordosis of the cervical and lumbar spines, as well as the kyphosis of the thoracic spine. The primary function of this curvature is to distribute the longitudinal forces that are exerted on the spinal column, as well as the secondary lateral shear forces that may be exerted. These forces are also absorbed and distributed by the muscular and capsular ligamentous structures of the vertebral column (Gharries, 2018).

Spinal stability is ensured by ligamentous structures that limit certain movements. This prevents any damage or deformation from occurring in the surrounding structures. Furthermore, the spine makes up the spinal canal. This serves as a port for the spinal cord and spinal nerves that pass into the peripheral neural structures beyond the spinal canal (Gharries, 2018).

During the paddling stroke, the spinal column provides support and stability as the draw knee and hip are extended during paddle movement in the water to help drive the draw hip backwards, producing rotation of the torso. This movement is combined with movement in the transverse plane of the shoulder girdle, thoracic and lumbar spines and the pelvic girdle. Faulty biomechanics or restricted movement in these structures will hamper the speed of the boat and may predispose the paddler to injury of these structures.

2.8.1 The motion segment The functional unit of the spine is known as the motion segment and is formed by two adjacent vertebrae. This structural segment is also formed by (Gharries, 2018): • Intervertebral space • Vertebral arches • Spinous processes • Transverse processes 17

• Soft tissue • Spinal nerves • The skin innervated by the spinal nerve The vertebral body is a block-shaped structure which forms the borders of the spinal column cranially and caudally. This structure has bony ridges which limit the weight-bearing surface of the intervertebral disc onto the vertebral bodies and act as an attachment site for fibrocartilage. The vertebral body is convex anteriorly and vertically orientated posteriorly. The vertebral body is composed of cancellous bone and is encapsulated compact bone. These structures ensure fault lines within the corpus, running cranial to caudal to the spine. This ensures the transmission of the axial load exerted during compression of the spinal column. The base and the endplates of the vertebral body are covered with hyaline cartilage (Gharries, 2018).

The vertebral arch is also referred to as the neural arch. This structure is posterior to the vertebral body and is formed dorsally by the lamina and laterally by the pedicles. The articular processes are located in the transition region between the pedicle and the lamina. These two adjacent segments form the facet joints. The lamina consists of two symmetrically fused bones. Three processes project from the vertebral arch, namely, the spinous process and the two transverse processes. The spinous process is located posteriorly and centrally in the vertebral column while the bilateral transverse processes are located at the junction of the pedicle and the lamina (Gharries, 2018).

The spinous process provides an attachment site for the surrounding musculature and ligamentous structures. In the cervical spine, these bony projections are bifurcated form C2 to C6 and merge from C7 caudally. In the thoracic spine, these bony projections are elongated and are orientated obliquely caudally, while in the lumbar spine they are more horizontally orientated, with a square shape (Gharries, 2018).

The transverse process varies in size, shape and orientation depending on the vertebral segment. In the cervical spine, this bony projection bears anterior and posterior tubercles. The transverse foramen is located between the tubercles and serves as a passageway for the vertebral artery. In the thoracic spine, these processes have articulating surfaces for rib tubercles to articulate with, whereas in the lumbar spine these processes have three tubercles, and are referred to as the costiform process, the mamillary process and the accessory process (Gharries, 2018).

Between the vertebral body and the vertebral arch lies a canal referred to as the vertebral foramen. The size and shape of this structure varies and depends on the segmental level in the spinal column. The combination of the adjacent vertebral foramen forms the vertebral canal. This structure forms a passageway for the spinal cord, meninges and associated structures to pass through. There is a transitional region in the vertebral 18

column which occurs in the lumbar spine. This region is lined with epidural fatty tissue and lies between the spinal canal and the intervertebral canal. This is the region where the spinal nerve roots pass through (Gharries, 2018). Each adjacent vertebra has an inferior and a superior vertebral notch. The combination of an inferior and superior vertebral notch from two adjacent vertebrae forms an intervertebral foramen. This foramen serves as an opening for the spinal nerve, meningeal branch, spinal artery and intervertebral vein (Gharries, 2018).

The articulating surfaces of the facet joints are covered by cartilage and encapsulated by a joint capsule. The function of the facet joint is to absorb and transmit compressive forces so that spinal movement can occur without injury. The movements are controlled via proprioceptors in the capsular ligaments. The articular surfaces in each region of the spine have varying angles of inclination, which allow varying degrees of rotation. The angle of inclination increases from a 45-degree angle in the cervical spine, to an 80-degree angle in the thoracic spine, to finally end with a 90-degree angle in the lumbar spine. Due to the angulation of the articular surface in the lumbar spine, rotational movements are restricted (Gharries, 2018).

Two adjacent vertebral bodies are connected by a fibrocartilaginous joint known as the intervertebral disc. This disc is attached to the vertebral bodies via the endplates. The intervertebral disc functions primarily to distribute loads to the surrounding bony structures. This structure also permits motion to occur in certain degrees per direction of motion. The intervertebral disc is composed of two parts, namely, the nucleus pulposus (NP) and the annulus fibrosus (AF) (Galbusera, Rijsbergen, Ito, Huyghe, Brayda-Bruno & Wilke, 2014).

The nucleus pulposus (NP) is located centrally in the disc. This structure consists of water-based, gel-like substance rich in proteoglycans, a small amount of collagen type II and elastin fibres. As a result, this structure has a strong water-binding capacity. The NP is avascular and serves the voltage shift of discs during spinal movements. The surrounding vessels supply this structure with nutrition via diffusion. Liquid is taken up by the disc overnight, thus increasing the height of the intervertebral disc (Galbusera et al., 2014).

The annulus fibrosus (AF) encapsulates the NP with a collagen type I-based concentric lamellar structure. Within each lamella, the fibres are aligned approximately 30 degrees with respect to the transverse plane of the vertebral endplates. The fibre angulation alternates between adjacent lamellae, with radial connecting collagen bundles occasionally being present between the lamellae. Most of the lamellae are filled with a proteoglycan-rich gel. Shock absorption is one of the primary functions of this structure, which acts as a protective mechanism against disc rupture. Fibres from the AF attach this structure to the vertebral body and

become continuous with the posterior longitudinal ligament. It may also share a low fibre content with the anterior longitudinal ligament (Galbusera et al., 2014).

A motion segment has functional ligamentous structures which stabilise the spine in the neutral position, thereby limiting range of movement. This prevents movement from exceeding the anatomical barrier, thus maintaining the integrity of the delicate structures.

2.8.2 The lumbar spine The lumbar spine is the section of the vertebral column that extends between the thorax and the sacrum. It consists of five vertebrae (L1 to L5) with their corresponding intervertebral discs and synovial joints (Kurutz, 2010).

The lumbar vertebrae are cylindrical in shape, with the anterior aspect being thicker than the posterior aspect. This forms the lumbar lordosis, which occurs as a result of the anteriorly convex curvature of the vertebral bodies. The superior and inferior surfaces of the vertebral body are covered by the bony endplates composed of thin perforated cortical bone. These perforations allow metabolites to diffuse from the bone to the central regions of the avascular discs (Kurutz, 2010).

The intervertebral discs allow for full range of motion to occur. The range of motion in the lumbar spine is restricted by the orientation of the facet joints. The facet joints of L3 to the sacrum are orientated more coronally from proximal to distal. This orientation allows for a greater range of flexion and extension movements in the sagittal plane but limits rotational movements. As a result, it is very unlikely that the lumbar spine will be affected by rotational instability. Two adjacent articular process in the lumbar spine form a locking mechanism to prevent axial rotation from occurring. This is accomplished via the orientation of the articular processes. The superior articular process is orientated dorsomedially while the inferior articular process is orientated ventrolaterally, thus effectively locking together when axial rotation of the lumbar spine is performed. This is a protective mechanism which prevents excessive shear and torsional strain being exerted on the intervertebral discs. The outermost fibres of the annulus fibrosis are the first restriction against abnormal micro-motion in the intact lumbar segment. The formation of the disc provides it with both the tension-resisting properties of a ligament and the compression-resisting properties of articular cartilage (Kurutz, 2010).

Lumbar intervertebral discs uniformly distribute applied stresses across their endplates under compressive and eccentric-compressive loading conditions. Excessive joint motion is limited by the sagittal alignment of

the facet joint and the joint capsule. The joint capsule is approximately 1 mm thick and attaches 2 mm from the articular margins. This structure limits axial rotation and backward sliding during extension (Kurutz, 2010).

2.8.3 The sacroiliac joint The sacroiliac joint is a strong diarthrodial weight-bearing compound joint. This joint is formed by the articulation between the sacrum and the ilium. The sacroiliac joint links and supports the axial skeleton with the inferior appendicular skeleton (Butt et al., 2015). These weight-bearing joints consist of anterior synovial joints and posterior syndesmotic joints. The anterior synovial joint is between the articulating surfaces of the sacrum and the ilium; the surfaces of these two structures are covered by articular cartilage. The posterior syndesmosis is located between the tuberosities of the sacrum and the ilium (Ghasemi-rad, Attaya, Lesha, Vegh, Maleki-Miandoab, Nosair et al., 2015). This joint differs from most synovial joints in that there is restricted mobility. This is as a result of the joint’s weight distributing functions. This joint transmits the body weight to the hip joints and lower limbs.

The sacroiliac joint is stabilised by three main ligaments – the anterior sacroiliac ligament, the interosseous ligament and the posterior sacroiliac ligament (Ghasemi-rad et al., 2015).

The anterior sacroiliac ligament extends from the sacral ala and the anterior surface of the sacrum to the anterior surface of the ilium. This ligament binds the ilium to the sacrum and prevents diastasis of the sacroiliac joint (Butt et al., 2015).

The interosseous ligament extends from the superior articular process and lateral crests of the first two sacral segments to the ilium. This ligament forms a bony interlocking mechanism between the ilium and the sacrum. The function of this mechanism is to prevent excessive movement between these two bony structures (Butt et al., 2015).

The posterior sacroiliac ligament connects the intermediate and lateral sacral crests to the posterior superior iliac spine and the posterior end of the internal lip of the iliac crest. The main function of this ligament is to bind the sacrum and the ilium, as well as to prevent the counter-nutation of the sacrum with respect to the ilium (Butt et al., 2015).

The sacroiliac joint’s main function is shock absorption as well as to transmit weight-bearing forces from the trunk and upper extremities to the lower extremities. The amount of shock absorption is directly proportionate to the amount of motion available at the sacroiliac joint. Torque conversion will also take place at this joint,

to allow transverse rotations that take place in the lower extremities to be transmitted up the vertebral column (Butt et al., 2015).

2.9 The lower limb Kayaking is an incredibly competitive sport. Therefore, to be successful and obtain a podium position, the athlete must complete the distance in the shortest time. To achieve this, the paddling technique needs to be performed with precision and the athlete must be able to create, maintain and increase the speed of the watercraft. This technique requires the action of the trunk and upper extremities, in combination with the lower limb musculature, to perform a complex motion using alternate left and right strokes in a cyclic manner.

2.9.1 The hip joint The hip joint is a ball and socket joint formed by the articulation of the femoral head and the acetabulum. The surrounding musculature, ligamentous structures, articular cartilage, capsules and bony anatomy ensure that maximal joint congruency is maintained. The body weight is transferred from the axial skeleton into the lower extremities. This is achieved when the osseous, ligamentous and muscular structures act together (Zaffagnini, Signorelli, Bonanzinga, Lopomo, Raggi, Sarsina et al., 2016).

The acetabular labrum is a fibrocartilaginous structure made up of circumferential collagen fibres. These fibres cover the entire surface of the acetabulum and become continuous with the transverse acetabular ligament. During physical activity, the acetabular labrum dissipates large forces that act on the joint. The acetabular labrum encompasses the femoral head, which seals the joint. This allows joint lubrication to occur and provides resistance to joint distraction (Zaffagnini et al., 2016).

The integrity of this joint is ensured by the surrounding ligamentous structures and the joint capsule. These ligaments include the iliofemoral, pubofemoral and the ischiofemoral ligaments. These ligaments surround the hip joint, with the strongest being the iliofemoral ligament. The anterior iliofemoral ligament extends from the anterior inferior iliac spine (ASIS) to the femoral intertrochanteric line. The function of this ligament is to restrict hip joint hyperextension. The pubofemoral ligament is positioned inferiorly and restricts excessive

abduction of the hip. The ischiofemoral originates posteriorly along the ischium and extends to the femoral neck. This ligament prevents excessive hip flexion (Anderson, Strickland & Warren, 2001).

The head and neck of the femur is encapsulated by the joint capsule. This capsule is strongest anteriorly and is reinforced posteriorly by the above ligaments (Jain & Clamp, 2020).

2.9.2 The knee joint The knee joint is a complex synovial joint that consists of two distinct articulations − the patellofemoral and the tibiofemoral joints (Kazemi, Dabiri & Li, 2013).

The patellofemoral joint is composed of the articulation of the patella with the patella groove of the femur. The patella is the largest sesamoid bone in the human body and provides protection to the underlying tibiofemoral joint by forming a bony shield. This bony structure serves as a biomechanical lever arm, which improves the effective extension capacity of the quadriceps muscle by increasing the moment arm of the patella tendon (Tecklenburg, Dejour, Hoser & Fink, 2006).

The patella also centralises the divergent forces of the quadriceps muscle and distributes the tension around the femur to the patellar tendon. The distal pole of the patella provides an attachment point for the patellar tendon. The articular surface of the patella has seven facets. When the knee is in the flexed position, three medial and three lateral facets articulate with the underlying femoral groove. The odd facet is located on the medial border of the underlying surface, and only articulates with the medial femoral condyle when the knee is hyperflexed (Tecklenburg et al., 2006).

The main tissues in the tibiofemoral joint are the femur, tibia, fibula, articular cartilages, menisci and ligaments (Kazemi et al., 2013). The ligamentous structures, in combination with the joint capsule, maintain the integrity of the joint by providing stability. The ligaments include the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments (Arya & Jain, 2013).

The anterior cruciate ligament (ACL) arises from the anteromedial aspect of the intercondylar area on the tibial plateau and extends superio-posteriorly to attach to the posteromedial aspect of the lateral femoral condyle. This ligament is fan-shaped and consists of two components – the anteromedial bundle (AMB) and the posterolateral bundle (PLB). The anteromedial bundle attaches to the roof of the intercondylar notch, whereas the posterolateral bundle is more vertically orientated and attaches to the wall of the intercondylar notch (Bawazeer & Goel, 2020). These bundles function at different angles of flexion, thus providing both anterior and rotational stability to the knee. The AMB is taut throughout knee range of motion, reaching 23

maximum tension between 45 and 60 degrees. The PLB is primarily taut in extension. These bundles contribute to the characteristic biomechanics of the knee (Yasuda, Van Eck, Hoshino, Fu & Tashman, 2011).

The posterior cruciate ligament (PCL) attaches to the posterior intercondylar area and extends anteroposteriorly to attach onto the lateral surface of the medial femoral condyle. This ligament contains two fibre bundles – the anterolateral bundle and the posteromedial bundle. The anterolateral bundle becomes taut during flexion, whereas the posterolateral bundle becomes taut during extension (Harner, Vogrin & Woo, 2001). The PCL provides posterior and rotational stability to the knee.

The medial collateral ligament extends from the medial femoral condyle to the anteromedial tibial crest. Anterior to the femoral attachment, this ligament is continuous with the medial patellofemoral ligament. Fibres blend with the medial retinaculum as well as with the meniscus. This limits movement of the meniscus and provides resistance against valgus forces to the knee joint (Wymenga, Kats, Kooloos & Hillen, 2006).

The lateral collateral ligament (LCL) extends from the lateral aspect of the femur, passes between the lateral epicondyle and supracondylar process to insert onto the lateral edge of the fibular head. The lateral fibres of the ligament continue distally and medial to the anterior arm of the long head of the biceps muscle. These fibres reinforce the fascia over the peroneus longus muscle of the lateral compartment of the leg. The posterior aspect of the ligament is connected to the lateral aponeurotic expansions of the short head of the biceps muscle and is covered laterally by the lateral aponeurosis of the long head of the biceps muscle. When the knee is in any of the flexed positions, the lateral collateral ligament is the major restraint to primary varus rotation (Espregueira-Mendes & Vieira da Silva, 2006).

Between the femur and the tibia are two wedge-shaped menisci. These structures are fibro-cartilaginous and are attached to the tibial plateau along the periphery via the coronary ligaments and to the femur via the ligaments of Humphrey and Wrisberg. The patellomeniscal ligaments ensure that these wedge-shaped structures are also attached to the patella. These ligaments arise from the anterior joint capsule. The superior surfaces of the menisci are concave, thus increasing the congruency between the femoral condyles. The inferior surfaces are flat, to accompany the relatively flat tibial plateau (Chivers & Howitt, 2009). These fibrocartilaginous structures provide space, stability and cushioning for the knee joint (Arya & Jain, 2013).

The menisci provide further stability to the joint and distribute weight-bearing forces. Secondarily, these structures provide nutrition, lubrication and distribute forces acting on the underlying cartilage. They may also promote proprioception to the knee joint (Chivers & Howitt, 2009).

The knee joint functions primarily to support body weight and facilitate locomotion. Locomotion is possible due the tibiofemoral joint, which allows relative motion of the femur on the tibia. This is facilitated through mechanical contacts between the cartilages and menisci (Kazemi et al., 2013). The flexion and extension of the knee joint facilitates forward or backward propulsion of the body.

2.9.3 The ankle joint The foot and ankle are made up of 26 individual bones, and in combination with the long bones of the lower limbs, form a total of 33 joints. The ankle joint complex is made up of the subtalar, talocalcaneonavicular and talocrural joints (Brockett & Chapman, 2016).

The subtalar joint is a triplanar, uniaxial joint. This joint is formed by the articulation of the calcaneus and the talus, which facilitates inversion and eversion movements of the foot (Brockett & Chapman, 2016).

The talocalcaneonavicular joint combines the junction between the talus and navicular, where anteriorly, the posterior aspect of the navicular articulates with the talar head, and the calcaneocuboid joint, the joint between the calcaneus and the cuboid. This joint shares a common axis of motion with the subtalar joint, so it may be considered as a part of the same functional unit. This joint also contributes to the eversion-inversion motion of the foot (Brockett & Chapman, 2016).

The ankle joint is also referred to as the talocrural joint. This joint is a three-bone synovial hinge joint designed for stability. The three bones that form this joint include the distal tibia and fibula, and the talus. This joint is composed of the articulation between the concave tibial plafond and the trochlea surface of the talus. The posterior malleolus is the located on the posterior aspect of the tibial plafond. The tibia extends medially as the medial malleolus, whereas the distal fibula is known as the lateral malleolus. These bones are held in place and stabilised by a complex array of three sets of ligaments. These ligaments include the medial ligament, the lateral ligament and the syndesmosis (Westerman & Porter, 2007).

The medial ligament is also known as the deltoid ligament, which fans out from the tip of the medial malleolus and attaches to the talus, calcaneum and the navicular. This ligamentous structure is the strongest restraint to talar pronation (Leardini, O’Connor, Catani & Giannini, 2000).

The lateral ligament consists of three independent structures known as the anterior and posterior talofibular ligaments, and the calcaneofibular ligament.

The anterior talofibular ligament (ATF) extends from the anterior edge of the lateral malleolus to the lateral aspect of the talar neck between the lateral articular facet and the mouth of the sinus tarsi. This ligament is the most important stabiliser of the ankle. This ligament is the primary restraint to supination and anterior talar translation at all positions of flexion (Leardini et al., 2000).

The posterior talofibular ligament (PTaF) originates in the fossa of the lateral malleolus and extends in a fan shape. This ligament has anterior and posterior fibres. The anterior fibres are short and insert laterally on the posterior edge of the talus. The posterior fibres are longer and insert on the medial aspect on the lateral tubercle of the posterior process of the talus. The PTaF ligament contributes to the stability of the ankle in all positions of dorsiflexion (Leardini et al., 2000).

The calcaneofibular ligament (CF) is a styloid-shaped ligament. This ligament extends from the anterior edge of the distal fibula to the mid-lateral surface of the calcaneus. This ligament does not act independently but acts with the ATF and the PTaF ligaments. It acts with the ATF ligament to limit supination in the plantarflexed and neutral positions, and together with the PTaF in dorsiflexion (Leardini et al., 2000).

The syndesmosis consists of three ligaments which hold the tibia and fibula in anatomical position to form the mortise. This ligamentous structure is also known as the distal tibiofibular syndesmosis. These ligaments include the interosseous membrane, the anterior tibiofibular ligament and the posterior tibiofibular ligament. The interosseous membrane originates from the fibular notch of the tibia and inserts at the same level on the anterior two-thirds of the medial fibular surface. The anterior tibiofibular ligament originates on the anterior tubercle of the distal tibia and the anterolateral part of the tibial epiphysis. This ligament inserts anteromedially on the upper portion of the lateral malleolus. The posterior tibiofibular ligament extends from the distal and lateral part of the tibial epiphysis to the posterior surface of the lateral malleolus (Leardini et al., 2000).

The most significant movement of the ankle joint complex is plantarflexion and dorsiflexion, which occurs in the sagittal plane. Other movements may include abduction and adduction as well as inversion and eversion, which occur in the transverse and frontal planes respectively. Supination and pronation are three-dimensional motions that occur as a result of combinations of the movements available in both the subtalar and tibiotalar joints. Supination is a combination of plantarflexion, inversion and adduction which causes the sole of the foot to face medially. Pronation is a combination of dorsiflexion, eversion and abduction which positions the sole of the foot laterally (Brockett & Chapman, 2016).

2.9.4 The foot There are 26 bones in the human foot, providing structural support. These bones can be grouped into three parts: seven tarsal bones, five metatarsal bones and fourteen phalanges (Panchbhavi, 2015).

The foot is divided into three parts, namely, the hindfoot, the midfoot and the forefoot. The hindfoot is composed of two of the seven tarsal bones, the talus, and the calcaneus, the midfoot contains the remaining tarsal bones while the forefoot contains the metatarsals and the phalanges (Panchbhavi, 2015).

The foot is formed by numerous bones and joints that are held together by three layers of ligaments. The bones in the foot are arranged to form three strong arches. These arches are arranged as follows – two lengthways and one across the foot. The ligaments, in combination with the tendons of the foot muscles, join the bones of the foot together. This maintains the position of the bones in the arched position but still allows some give and springiness. During locomotion, the foot arch is subjected to considerable deformations, resulting in elastic energy storage in the longitudinal foot arch for propulsion (Wright, Ivanenko & Gurfinkel, 2011).

The foot is considered a functional unit with two important aims − supporting the body weight when the foot is static and serving as a lever to propel the body forward in walking and running when the foot is dynamic (Wright et al., 2011).

CHAPTER THREE: METHODOLOGY

3.1 Introduction This chapter describes the research methodology, including the research process, survey development and ethical considerations.

3.2 Study design This study took the form of a cross-sectional, quantitative, exploratory descriptive survey. The survey, which was adapted from the survey done by Lepera (2010) with the assistance of the University of Johannesburg’s statistical department (STATKON), was administered to an appropriate sample of competitive kayakers training at Dabulamanzi Canoe Club in Johannesburg.

3.3 Participant recruitment Permission to conduct the study was granted by the chairman of Dabulamanzi Canoe Club (Appendix A), the Faculty of Health Sciences Research Ethics Committee (REC-129-2019) (Appendix B) and the Higher Degrees Committee (HDC-01-68-2019) (Appendix C) of the University of Johannesburg.

A sample of 205 members at Dabulamanzi Canoe Club was sent a link via email to complete the online questionnaire using the MyEco website. The club sent a notice out on their monthly mailer to inform members that the study would be conducted at the Club. Hard copies of the survey were also handed out after time- trials and training sessions to obtain a maximum response.

3.4 Inclusion criteria The participants had to comply with the following criteria in order to participate in this study: • Participants had to be between 18 and 50 years of age. A lower limit of 18 was set to eliminate the need for parental consent whereas an upper limit of 50 was set as degeneration in the spine starts from that age (Galbusera et al., 2014). • Participants had to be registered competitive members at Dabulamanzi Canoe Club. • Participants had to be registered competitive members with the Gauteng Canoe Union. • Participants had to paddle at least twice a week.

3.5 Sample selection and size The researcher selected kayakers from Dabulamanzi Canoe Club as the club has approximately 1000 members, of which 205 are registered active members. A sample of 55 participants was obtained, however,

due to the small sample size the results were specific to this group and cannot be compared to the greater kayaking population.

3.6 Preparation for data collection The initial step in preparing for data collection was to adapt the survey. A pilot study was performed to ensure that the survey would be interpreted correctly. Participants for the pilot study responded within a week. Based on these responses, amendments were made to the questionnaire. Questions were adapted so that the participants could respond with ease and understanding. Certain questions in the online questionnaire were changed in such a manner that the participants were required to answer it. Dabulamanzi Canoe Club was then approached to aid the researcher in the distribution of the survey. This was initially achieved through the Club’s monthly mailer. Hard copies were subsequently handed out after time-trials and practice sessions to increase the number of responses.

3.7 Questionnaire The self-administered questionnaire was adapted from Lepera’s (2010) questionnaire on shoulder pain in competitive male wheelchair basketball players in Gauteng and Haley and Nichols’ (2009) questionnaire on injuries and medical conditions affecting competitive outrigger canoe paddlers in O’ahu. The questionnaire (Appendix D) was adapted with the assistance of STATKON in order to capture quantitative data. STATKON also assisted with the layout and coding of the questionnaire. As mentioned above, the survey was pilot tested to ensure validity and reliability.

3.8 Questionnaire content The questionnaire contained three sections. Section A comprised of questions that participants needed to comply with before they could continue with the rest of the survey. Section B comprised of questions relating to demographics. Section C comprised of questions on the participants’ daily personal and paddling habits, whether they had sustained an injury while paddling and under what conditions this injury had occurred. The participants were also asked whether they had ever received chiropractic treatment and if they ever considered seeing a chiropractor.

3.9 Data collection A pilot study was run on 5 participants to determine if the questionnaire was easy to understand and complete. A target group of 205 participants was utilised in this study. However, a convenience sample of 55 responses was obtained due to the reluctance of some members to participate in the study.

The participants received an email from Dabulamanzi Canoe Club, with a link to participate in the study. When the participants clicked on the link they were taken to an independent website where an information letter was included (Appendix E). The information letter explained to each participant what was expected of them. The participants were informed that by clicking on the ‘Start Survey’ button they were giving informed consent to take part in the study. They were then able to complete the survey. The entire process took approximately 10-20 minutes.

This was assumed to be the most advantageous way of conducting the survey due to the large sample size and varying daily schedules, as online questionnaires are the most time and cost-effective method of sampling (Statpac Inc, 2014). A disadvantage of such surveys, however, is that due to the distribution via email, the response rates tend to be low and the researcher does not have absolute control over who completes the survey.

However, due to the poor response to the online survey, the survey was printed out and distributed to the participants in no particular order. The surveys were handed out after time-trials and training sessions. No personal details were recorded on the survey. All participants received an information letter (Appendix E) and a consent form (Appendix F). The researcher explained to each participant exactly what was expected from them and they were then asked to complete the survey. This proved to be an effective strategy as the response rate from the participants was high due to the presence of the researcher.

Once the survey was completed, it was randomly placed in a box in a designated room. There were two sealed, labelled boxes for the consent form and the questionnaire. Anonymity was maintained at all times. These boxes were only opened by the researcher when the data analysis commenced.

Once the data from all 55 cases was captured, STATKON was consulted for analysis of the results. The STATKON approval form is included as Appendix G.

3.10 Data analysis and statistical procedure Data analysis was conducted by the researcher with advice and assistance from a statistician at STATKON. Data was captured on Microsoft Excel using the IB SPSS (Statistical Package for the Social Sciences) version 25.0 software programme. Data analysis consisted of frequencies, descriptive statistics and custom tables. Frequencies describe categorical data in order to determine how often each answer was given. Descriptive statistics made use of mean, median, interquartile range, standard deviation, minimum and maximum to describe the continuous data. Custom tables were used to interpret the data collected from

the questions where participants provided more than one answer. The data was also compiled into two different tables to determine whether certain injuries were more prevalent in one sporting discipline.

3.11 Ethical considerations As mentioned in section 3.6, ethical clearance was granted for conducting the survey. All participants who showed interest in the online questionnaire were requested to read the information letter (Appendix E). The participants were informed that by clicking on the ‘Start Survey’ button that they were giving informed consent to participate in this study. Upon beginning the study, participants were clearly informed that participation was entirely voluntary and that they were free to withdraw from the study at any stage, before the submission of the questionnaire.

The participants who showed interest in completing the printed-out survey were given the relevant documentation and were requested to read the information letter (Appendix E) and sign the consent form (Appendix F). The researcher explained to the participants exactly what was expected of them and that they were free to withdraw before the submission of the survey. Once participants submitted their completed surveys it was not available for correction or retraction due to there being no personal details on the documents. The participants were shown where they could submit their completed consent form and questionnaire.

The information letter and consent form outlined the names of the researcher, purpose of the study and benefits of partaking in the study. They were clearly informed that their answers were completely anonymous and confidential. Personal details, in any form, were not required for the completion of the survey. The participants’ privacy was protected as only the researcher and the statistician from STATKON would have access to the information. The information obtained from the questionnaire was converted into data and therefore could not be traced back to the individual.

Potential benefits and risks of participation in the research were communicated to the participants in the information letter that they had access to. The participants were informed that there were no direct benefits to them. Their participation helped the researcher to better understand which injuries commonly affected paddlers and how these injuries could potentially be prevented from occurring in future paddlers. There were no risks involved with completing the survey.

If any further questions arose from the participant, these were explained by the researcher. The participants will also have access to the results of the study, once it is completed, by contacting the researcher.

3.12 Originality check Upon completion of the dissertation, an originality check of the content was completed with the use of the anti-plagiarism software, Turnitin. A report (Appendix H) was received, which compared the similarity of the work to other sources and revealed a 19% similarity.

CHAPTER FOUR: RESULTS

4.1 Introduction In this chapter, the results of the data analysis are presented and briefly explained. As described in the previous chapter, the survey was distributed to 205 members of Dabulamanzi Canoe Club, who were registered with the Gauteng Canoe Union as active racing members. A total of 55 valid responses was received (26.83% of all registered kayakers). The responses were statistically analysed. No statistical inference could be made because of too many expected counts in these contingency tables being less than 5. Therefore, the results did not meet the mathematical assumption with which to perform chi-squared tests for independence. Thus, no references could be made for the general kayaking population, only to this specific sample of kayakers.

Due to the relatively small sample size used in this study, trends were evaluated rather than statistically significant differences. A study done by Faber and Fonseca (2014), stated that small sample sizes may undermine the internal and external validity of a study. This indicated that there was an increased chance of interpreting a true assumption as a false one. Moreover, not all the questions were answered by all the participants, therefore the number of responses, or (n) value, varied per question.

4.2 Demographic Data This section describes the demographics of the sample, namely, the participants’ gender and age.

4.2.1 Gender Data was collected from 55 survey participants on their gender, as shown in Table 1 below.

Table 1: Gender ratio of the particpants Frequency (n) Percentage (%)

Female 9 16.4

Male 45 81.8

Other 1 1.8

Total 55 100

In total, there were 45 male participants, making up 81.8% of the sample and 9 female participants who constituted 16.4% of the sample. There was one participant who indicated ‘Other’, making up 1.8% of the

sample. There was a 65.4% difference between female and male response rates, with a greater response rate from the males. The sample was therefore male-dominated.

4.2.2 Participants’ age Data was collected from 55 survey participants. Table 2 below shows the sample distribution by age.

Table 2: Age range of the participants Frequency (n) Percentage (%)

18 - 24 19 34.5 25 - 34 9 16.4 35 - 44 9 16.4 45 - 50 18 32.7 Total 55 100

Of the 55 participants, 34.5% were between 18 and 24 years, 16.4% between 25 and 34 years, 16.4% between 35 and 44 years and 32.7% between 45 and 50 years. The modal age group for the participants was therefore the 18 to 24 years age group. The groups with the least number of participants were the 25 to 34 and 35 to 44 year age-group with a frequency of 9 participants or 16.4% of the sample.

4.3 Kayaking and competing history Data on the sample’s kayaking history and experience was also collected. This data is analysed in this section.

4.3.1 Kayaking experience Figure 3 indicates how many years the participants had been paddling.

Figure 4.3:1 Number: Number of of years years the the participants participants had had been been paddling paddling

The average amount of years that the participants had been paddling was 13.85 years (SD=11.573), with a range of 41. The maximum was 42 years and the minimum was 1 year.

4.3.2 Competitive history Figure 4 below shows how many years the participants had been active, competitive members at Dabulamanzi Canoe Club.

Figure 4: Number of years the participants had been competitive members

On average, the participants have been competitive members for 9.67 years (SD=9.365), with a maximum of 40 years and a minimum of 1 year. The range of this data is 39 years.

4.3.3 Kayaking training Data was collected on the amount of days spent training at Emmarentia Dam per week as well as the number of hours spent training and competing in events per week.

Table 3: Number of days per week the participants trained at Emmarentia Dam Frequency (n) Percentage (%)

1 day a week 9 16.4

More than 1 day a week 46 83.6

Total 55 100

In the total sample (n=55), 16.4% of participants trained once a week while 83.6% trained more than once a week. Most of the participants trained more than once a week (modal class: more than 1 day a week).

Table 4: Number of hours per week the participants spent training and competing 10- 13- 16- 21- 0 1-3 4-6 7-9 ≥ 30 Total 12 15 20 30 Average hours per Count week spent 10 24 4 6 0 0 1 0 0 45 (n) training at Emmarentia Dam % 22.2% 53.3% 8.9% 13.3% 0% 0% 2.2% 0% 0% 100% Average hours per Count week spent 1 22 13 7 2 0 0 0 0 45 (n) competing in canoeing events % 2.2% 48.9% 28.9% 15.6% 4.4% 0% 0% 0% 0% 100%

Only 45 of the 55 participants indicated how many hours they spent training and competing per week. Of these, 22.2% spent 0 hours training, 53.3% spent 1-3 hours training, 8.9% spent 4-6 hours training, 13.3% spent 7-9 hours training and only 2.2% spent 16-20 hours training at Emmarentia Dam per week. None of the participants trained for more than 21 hours per week. The average amount of hours per week spent training at the dam was 1-3 hours.

Of the 45 participants, 2.2% spent 0 hours competing in canoeing events, whereas 48.9% spent 1-3 hours competing, 28.9% spent 4-6 hours competing, 15.6% spent 7-9 hours competing and 4.4% spent 10-12 hours per week competing in canoeing events. None of the 45 participants spent more than 12 hours per week competing in canoeing events. The average amount of hours per week spent competing in canoeing events was 1-3.

The average amount of hours that the participants spent training at Emmarentia Dam and competing in canoeing events per week was 1-3 hours. Comparatively, the kayakers on average spent the same amount of time training as they did competing in events.

4.4. Kayaking events Data was collected on the events that the participants took part in as well as the kayak(s) that they used and the stability of the watercrafts. Table 5 below indicates which events the participants took part in while Table 6 indicates which category of kayaking the participants competed in.

Table 5: Events the participants took part in Did not participate Participated Total Q14.1 K1 (Single) n 0 55 55 % 0.0% 100% 100% Q14.2 K2 (Double) n 19 36 55 % 34.5% 65.5% 100% Q14.3 K3 (Three) n 43 12 55 % 78.2% 21.8% 100% Q14.4 K4 (Four) n 50 5 55 % 90.9% 9.1% 100%

In the sample, 100% of the participants took part in K1 (single) events, 65.5% took part in K2 (double) events, 21.8% took part in K3 (three) events and only 9.1% of the participants took part in K4 (four) events.

Table 6: Category of events the participants competed in Frequency (n) Percentage (%)

Sprinting (200m – 5000m) 15 27.3 Marathons (10km – 100km) 29 52.7 Both 11 20 Total 55 100

All 55 participants completed this question. In the total sample, 27.3% took part in sprinting, 52.7% took part in marathons and 20% took part in both events. The majority of the participants took part in marathon events.

4.5. Stability of the kayak Data was collected to evaluate the stability of the kayaks that the participants used, as shown in Table 7 below.

Table 7: Stability of the kayaks used by the participants Unmarked Marked Total Q17.1 Stable n 41 14 55 % 74.5% 25.5% 100% Q17.2 Intermediate n 35 20 55 % 63.6% 36.4% 100% Q17.3 Unstable n 30 25 55 % 54.5% 45.5% 100%

In the sample (n=55), 25.5% of the participants used a stable kayak, 36.4% of the participants used an intermediate kayak and 45.5% of the participants used an unstable kayak. The modal group of participants were those who used an unstable kayak to compete in events. Very few participants used a stable kayak.

4.6 Participants’ injury record Data was collected to establish whether the participants had sustained any injuries during their paddling career. Further analysis was done to compare if these injuries were related to age or the amount of years they had been paddling.

4.6.1 Paddling injuries Data was collected from the 55 participants to establish how many had sustained an injury during their paddling career, as shown in Table 8. Data was also collected to determine whether the participants were predisposed to injury prior to their paddling career, as shown in Table 9.

Table 8: Number of participants injured while paddling Frequency (n) Percentage (%)

Yes 40 72.7 No 15 27.3 Total 55 100

In the sample (n=55), 72.7% of the participants had been injured while paddling while the remaining 27.3% had not sustained an injury. The majority of the sample had therefore been injured at some point during their paddling career.

Table 9: Participants’ predisposition to injury prior to their paddling career Frequency (n) Percentage (%)

Yes 13 23.6 No 42 76.4 Total 55 100

In the sample (n=55), only 23.6% of the participants stated that they were pre-disposed to the injury they had sustained prior to their paddling career whereas the majority (76.4%) stated that they were not. Most of the participants had therefore sustained their injuries during their paddling career and were not predisposed to the development of these injuries.

4.6.2 Comparison between participants’ age and the development of a paddling injury Data was collected from the 55 participants to establish whether there was a relationship between the participants’ age and the development of a paddling injury. Table 10 below shows these findings.

Table 10: Cross-tabulation between the participants’ age and whether they had been injured while paddling Cross-tabulation

Have you ever been Total injured while paddling? Yes No Age 18 - 24 n 14 5 19 % within Age: 73.7% 26.3% 100% 25 - 34 n 5 4 9 % within Age: 55.6% 44.4% 100% 35 - 44 n 7 2 9 % within Age: 77.8% 22.2% 100% 45 - 50 n 14 4 18 % within Age: 77.8% 22.2% 100% Total n 40 15 55 % within Age: 72.7% 27.3% 100%

In the sample (n=55), 73.7% of the participants in the 18 to 24 age group indicated that they had been injured while paddling, 55.6% of the participants in the 25 to 34 age group indicated that they had been injured while paddling, 77.8% of the participants in the 35 to 44 age group indicated that they had been injured while paddling and 77.8% of the participants in the 45 to 54 age group indicated that they had been injured while paddling. The injuries seemed to be equally spread out across all age groups. Pearson Chi-Square test revealed a p-value of 0.638, which indicated that there was no statistically significant relationship between the development of an injury and the participants’ age.

4.6.3 Comparison between participants’ paddling experience and the occurrence of a paddling injury Data was collected to establish whether there was a correlation between the number of years the participants had been paddling and the development of an injury during their paddling career. Table 11 below illustrates this comparison.

Table 11: Cross-tabulation between the participants’ paddling experience and the occurrence of an injury Cross-tabulation

Have you ever been Total injured while paddling? Yes No How many years 1 - 5 years n 12 6 18 have you been % within How many 66.7% 33.3% 100% paddling? years have you been paddling? 6 – 16 years n 15 4 19 % within How many 78.9% 21.1% 100% years have you been paddling? 17 – 42 years n 13 5 18 % within How many 72.2% 27.8% 100% years have you been paddling? Total n 40 15 55 % within How many 72.7% 27.3% 100% years have you been paddling?

In the sample (n=55), 66.7% of the participants who had been paddling for 1 to 5 years indicated that they had been injured while paddling, 78.9% of the participants who had been paddling for 6 to 16 years indicated that they had been injured while paddling and 72.2% of the participants who had been paddling for 17 to 42 years indicated that they had been injured while paddling. The modal group was the participants who had been paddling for 6 to 16 years. Pearson Chi-Square test revealed a p-value of 0.702, which indicated that there was no statistically significant relationship between the development of an injury and the participants’ paddling experience.

4.6.4 Recorded injuries Data was collected on the participants’ history of injuries they had sustained while paddling. The following regions were focused on: the head, neck, shoulders, elbows, hands and wrists, lower back, hips, knees, ankles and feet. These regions will be discussed in further detail below.

4.6.4.1 Head injuries The following data was collected to find out the prevalence of head injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed the participants to head injuries as well as which injuries the participants had sustained. This is indicated in the tables below.

Table 12: Number of participants who sustained a head injury Frequency (n) Percentage (%)

Yes 7 17.1 No 34 82.9 Total 41 100 Missing 14 Total 55

In the sample (n=41), 17.1% of the participants stated they sustained an injury to the head while the remaining 82.9% stated that they had not sustained an injury. The majority of the participants had therefore not sustained a head injury during their paddling career.

Table 13: Types of head injury sustained by the participants Injury Frequency (n) Percentage (%)

Wounds or lacerations 5 71.4 Concussion 1 14.3 Fractured eye socket 1 14.3 Total 7 100

In the sample (n=7), 71.4% of the participants had sustained wounds or lacerations, 14.3% had concussion and 14.3% had fractured an eye socket. The most common head injuries among these participants were wounds or lacerations.

Table 14: Class of water the participants were on when they sustained the head injury Frequency (n) Percentage (%)

Class 0 2 33.3 Class 4 3 50 Class 5 1 16.7 Total 6 100 Missing 1 Total 7

In the sample (n=6), 33.3% of the participants had sustained a head injury on a Class 0 waterbody, 50% on a Class 4 waterbody and 16.7% on a Class 5 waterbody. The modal group was a Class 4 waterbody, which may indicate that most of the head injuries had occurred on this class of waterbody.

Table 15: Age of the participants who sustained a head injury Frequency (n) Percentage (%)

16 2 33.3 29 1 16.7 30 1 16.7 39 1 16.7 40 1 16.7 Total 6 100 Missing 1 Total 7

In the sample (n=6), 33.3% of the participants were 16 years old when they sustained the head injury, 16.7% were 29 years old, 16.7% were 30 years old, 16.7% were 39 years old and 16.7% were 40 years old.

Table 16: Participants who had recurrent head injuries Frequency (n) Percentage (%)

Yes 2 33.3 No 4 66.7 Total 6 100 Missing 1 Total 7

Of the 7 participants, 33.3% stated that their head injury was recurrent while the remaining 66.7% stated that it was not recurrent. Most of the head injuries were therefore not recurrent.

Table 17: Participants who received treatment for their head injury Frequency (n) Percentage (%)

Yes 2 33.3 No 4 66.7 Total 6 100 Missing 1 Total 7

Out of the 6 participants, only 33.3% received treatment for their head injury while the remaining 66.7% did not receive any treatment.

Table 18: Cross-tabulation between the category the participants competed in and the head injury

Cross-tabulation

Q20.1.1 Have you ever Total sustained an injury to your head while paddling? Yes No Q15 What Sprinting (200m – n 1 10 11 category do you 5000m) % within Q15 What 9.1% 90.9% 100% compete in? category do you compete in? Marathons (10km – n 4 19 23 100km) % within Q15 What 17.4% 82.6% 100% category do you compete in? Both n 2 5 7 % within Q15 What 28.6% 71.4% 100% category do you compete in? Total n 7 34 41 % within Q15 What 17.1% 82.9% 100% category do you compete in?

In the sample (n=41), 1 out of 11 participants competing in the sprinting category sustained a head injury, 4 out of 23 participants competing in the marathon category sustained a head injury, and 2 out of 7 participants competing in both events sustained a head injury. In all the categories, relatively few paddlers sustained head injuries. Pearson Chi-Square test revealed a p-value of 0.563, which indicated that there was no statistically significant relationship between the development of a head injury and the category that the participants’ competed in.

4.6.4.2 Neck injuries The following data was collected to find out the prevalence of neck injuries in sprinting and marathon kayaking. A comparison was made to find out which event predisposed the participants to the occurrence of neck injuries as well as the specific injuries that the participants sustained. This is indicated in the tables below.

Table 19: Number of participants who sustained a neck injury Frequency (n) Percentage (%)

Yes 7 17.1 No 34 82.9 Total 41 100 Missing 14 Total 55

In the sample (n=41), 17.1% of participants sustained an injury to their neck while the remaining 82.9% did not. This indicates that most of the participants had not sustained any neck injuries.

Table 20: Types of neck injury sustained by the participants Injury Frequency (n) Percentage (%) Nerve entrapment 2 25 Strained muscles 2 25 Acute vertebra damage 1 12.5 Wounds or laceration 1 12.5 Sprained ligaments 1 12.5 Overuse 1 12.5 Total 8 100

In the sample (n=8), 12.5% of the participants had acute vertebral damage, 12.5% had wounds or lacerations, 25% had nerve entrapments, 25% had strained muscles, 12.5% had sprained ligaments and 12.5% had overuse injuries. The most commonly reported neck injuries among the participants were entrapped nerves (25%) and strained muscles (25%).

Table 21: Class of water the participants were on when they sustained the neck injury Frequency (n) Percentage (%)

Class 0 3 50 Class 2 2 33.3 Class 3 1 16.7 Total 6 100 Missing 1 Total 7

In the sample (n=6), 50% of the participants sustained a neck injury on a Class 0 waterbody, 33.3% sustained an injury on a Class 2 waterbody and the remaining 16.7% sustained a neck injury on a Class 3 waterbody. From the data gathered above, most of the participants sustained a neck injury while they were competing or training on a Class 0 waterbody.

Table 22: Age of the participants who sustained a neck injury Frequency (n) Percentage (%)

14 1 14.3 16 1 14.3 23 1 14.3 25 1 14.3 30 1 14.3 39 1 14.3 40 1 14.3 Total 7 100

For the 7 participants who sustained a neck injury, the age range was from 14 to 40 years. In the sample, 14.3% of the participants were 14 years old, 14.3% were 16 years old, 14.3% were 23 years old, 14.3% were 25 years old, 14.3% were 30 years old, 14.3% were 39 years old and 14.3% were 40 years old. The prevalence of neck injury was equally distributed among the different age groups.

Table 23: Participants who had recurrent neck injuries Frequency (n) Percentage (%)

Yes 5 83.3 No 1 16.7 Total 6 100 Missing 1 Total 7

In the sample (n=6), 83.3% of the participants stated that their neck injury was recurrent while the remaining 16.7% stated that it was not recurrent. Most of the neck injuries were therefore recurrent.

Table 24: Participants who received treatment for their neck injury Frequency (n) Percentage (%)

Yes 4 57.1 No 3 42.9 Total 7 100

In the sample (n=7), 57.1% of participants received treatment for their injury while 42.9% did not. Most of the participants therefore did receive treatment for their neck injury.

Table 25: Cross-tabulation between the category the participants competed in and the neck injury Cross-tabulation

Q20.2.1 Have you ever Total sustained an injury to your neck while paddling? Yes No Q15 What Sprinting (200m – n 3 8 11 category do you 5000m) % within Q15 What 27.3% 72.7% 100% compete in? category do you compete in? Marathons (10km – n 3 20 23 100km) % within Q15 What 13.0% 87.0% 100% category do you compete in? Both n 1 6 7 % within Q15 What 14.3% 85.7% 100% category do you compete in? Total n 7 34 41 % within Q15 What 17,1% 82.9% 100% category do you compete in?

In the sample (n=41), 3 of the 11 participants competing in the sprinting category sustained a neck injury, 3 of the 23 participants competing in the marathon category sustained a neck injury, and 1 of 7 participants competing in both events sustained a neck injury. In all the categories, relatively few paddlers sustained neck injuries. Pearson Chi-Square test revealed a p-value of 0.574, which indicated that there was no statistically significant relationship between the development of a neck injury and the category that the participants’ competed in.

4.6.4.3 Shoulder injuries The following data was collected to find out the prevalence of shoulder injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed the participants to shoulder injuries as well as the type of injury that they sustained. This is indicated in the tables below.

Table 26: Number of participants who sustained a shoulder injury Frequency (n) Percentage (%)

Yes 24 58.5 No 17 41.5 Total 41 100 Missing 14 Total 55

In the sample (n=41), 58.5% of participants sustained a shoulder injury during their career while 41.5% did not. Most of the participants therefore sustained an injury to the shoulder during their paddling career.

Table 27: Types of shoulder injury sustained by the participants Injury Frequency (n) Percentage (%) Muscle strain 6 25 Rotator cuff injury 5 20.8 Ligamentous sprain 5 20.8 Dislocated shoulder 3 12.5 Overuse 3 12.5 Broken ribs 1 4.2 Nerve entrapment 1 4.2 Total 24 100

In the sample (n=24), 20.8% of the participants had a rotator cuff injury, 12.5% had a dislocated shoulder, 4.2% had broken ribs, 25% had muscle strains, 20.8% had ligamentous sprains, 12.5% had overuse injuries and 4.2% had entrapped nerves. The most commonly stated shoulder injuries were muscle strains (25%), ligamentous sprains (20.8%) and rotator cuff injuries (20.8%).

Table 28: Class of water the participants were on when they sustained the shoulder injury Frequency (n) Percentage (%)

Class 0 8 36.4 Class 1 5 22.7 Class 2 2 9.1 Class 3 4 18.2 Class 4 2 9.1 Class 5 1 4.5 Total 22 100 Missing 2 Total 24

In the sample (n=22), 36.4% of the participants sustained an injury on a Class 0 waterbody, 22.7% on a Class 1 waterbody, 9.1% on a Class 2 waterbody, 18.2% on a Class 3 waterbody, 9.1% on a Class 4 waterbody and 4.5% on a Class 5 waterbody. The majority of the participants therefore sustained a shoulder injury on a Class 0 waterbody.

Table 29: Age of the participants who sustained a shoulder injury Frequency (n) Percentage (%)

15 1 4.3 17 1 4.3 18 4 17.4 20 3 13 23 2 8.7 30 1 4.3 31 1 4.3 33 1 4.3 34 1 4.3 35 1 4.3 39 1 4.3 40 2 8.7 41 2 8.7 44 1 4.3 50 1 4.3 Total 23 100 Missing 1 Total 24

For the 23 participants who sustained a shoulder injury, the age range was from 15 to 50 years old. The age groups which sustained the most shoulder injuries were 18 (17.4%) and 20 (13.0%) years old.

Table 30: Participants who had recurrent shoulder injuries Frequency (n) Percentage (%)

Yes 16 72.7 No 6 27.3 Total 22 100 Missing 2 Total 24

In the sample (n=22), 72.7% of the participants stated that their shoulder injury was recurrent while the remaining 27.3% stated that it was not recurrent. Most of the participants therefore had recurrent shoulder injuries.

Table 31: Participants who received treatment for their shoulder injury Frequency (n) Percentage (%)

Yes 18 78.3 No 5 21.7 Total 23 100 Missing 1 Total 24

In the sample (n=23), 78.3% of the participants received treatment for their shoulder injury while the remaining 21.7% did not. This indicates that most of the participants did receive treatment for their shoulder injury.

Table 32: Cross-tabulation between the category the participants competed in and the shoulder injury

Cross-tabulation

Q20.3.1 Have you ever Total sustained an injury to your shoulders while paddling? Yes No Q15 What Sprinting (200m – n 6 5 11 category do you 5000m) % within Q15 What 54.5% 45.5% 100% compete in? category do you compete in? Marathons (10km – n 13 10 23 100km) % within Q15 What 56.5% 43.5% 100% category do you compete in? Both n 5 2 7 % within Q15 What 71.4% 28.6% 100% category do you compete in? Total n 24 17 41 % within Q15 What 58.5% 41.5% 100% category do you compete in?

In the sample (n=41), 6 of the 11 participants competing in the sprinting category sustained a shoulder injury, 13 of the 23 participants competing in the marathon category sustained a shoulder injury and 5 of the 7 participants competing in both events sustained a shoulder injury. Of the 24 participants who sustained shoulder injuries, 13 competed in marathon events. Pearson Chi-Square test revealed a p-value of 0.745, which indicated that there was no statistically significant relationship between the development of a shoulder injury and the category that the participants’ competed in.

4.6.4.4 Elbow injuries The following data was collected to find out the prevalence of elbow injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed participants to elbow injuries as well as the type of injury they were likely to sustain. This is indicated in the tables below.

Table 33: Number of participants who sustained an elbow injury Frequency (n) Percentage (%)

Yes 9 22 No 32 78 Total 41 100 Missing 14 Total 55

Of the sample of 41 participants, 22% stated that they had sustained an injury to their elbow while 78% stated that they had not. Most of the participants had therefore not sustained an elbow injury.

Table 34: Types of elbow injury sustained by the participants Injury Frequency (n) Percentage (%)

Tennis elbow 5 55.6 Tendonitis 2 22.2 Bruise 1 11.1 Strain 1 11.1 Total 9 100

Of the 9 participants who sustained an injury to their elbow, 11.1% had bruises, 11.1% had muscle strains, 22.2% had tendonitis and 55.6% had tennis elbow. The most commonly recorded elbow injury was tennis elbow.

Table 35: Class of waterbody the participants were on when they sustained the elbow injury Frequency (n) Percentage (%)

Class 0 3 33.3 Class 1 1 11.1 Class 3 1 11.1 Class 4 2 22.2 Class 5 2 22.2 Total 9 100

In the sample (n=9), 33.3% of the participants were on a Class 0 waterbody, 11.1% were on a Class 1 waterbody, 11.1% were on a Class 3 waterbody, 22.2% were on a Class 4 waterbody and 22.2% were on a Class 5 waterbody. Most of the participants sustained their elbow injury while they were on a Class 0 waterbody.

Table 36: Age of the participants who sustained an elbow injury Frequency (n) Percentage (%)

15 1 11.1 17 1 11.1 25 1 11.1 29 1 11.1 30 1 11.1 39 2 22.2 44 1 11.1 47 1 11.1 Total 9 100

For the 9 participants who sustained an elbow injury, the age range was from 15 to 47 years old. In the sample, 11.1% of the participants were 15 years old, 11.1% were 17 years old, 11.1% were 25 years old, 11.1% were 29 years old, 11.1% were 30 years old, 22.2% were 39 years old, 11.1% were 44 years old and 11.1% were 47 years old when they sustained an injury to their elbow. The age group with the most frequent injury was 39 years old. There was no age group which had vastly more injuries than the other.

Table 37: Participants who had recurrent elbow injuries Frequency (n) Percentage (%)

Yes 5 55.6 No 4 44.4 Total 9 100

In the sample (n=9), 55.6% of participants stated that their elbow injury was recurrent while the remaining 44.4% stated that it was not recurrent. Most of the participants therefore had a recurring elbow injury.

Table 38: Participants who received treatment for their elbow injury Frequency (n) Percentage (%)

Yes 5 55.6 No 4 44.4 Total 9 100

In the sample (n=9), 55.6% of the participants received treatment for their injury while 44.4% did not. The majority of the participants therefore did receive treatment for their elbow injury.

Table 39: Cross-tabulation between the category the participants competed in and the elbow injury Cross-tabulation

Q20.4.1 Have you ever Total sustained an injury to your elbows while paddling? Yes No Q15 What Sprinting (200m – n 1 10 11 category do you 5000m) % within Q15 What 9.1% 90.9% 100% compete in? category do you compete in? Marathons (10km – n 8 15 23 100km) % within Q15 What 34.8% 65.2% 100% category do you compete in? Both n 0 7 7 % within Q15 What 0% 100% 100% category do you compete in? Total n 9 32 41 % within Q15 What 22% 78% 100% category do you compete in?

In the sample (n=41), 1 of the 11 participants competing in the sprinting category sustained an elbow injury, 8 of the 23 participants competing in the marathon category sustained an elbow injury and 0 of the 7 participants competing in both events sustained an elbow injury. Of the 9 participants who sustained elbow injuries, 8 competed in marathon events. In all the categories, relatively few paddlers sustained elbow injuries. Pearson Chi-Square test revealed a p-value of 0.073, which indicated that there was no statistically significant relationship between the development of an elbow injury and the category that the participants’ competed in.

4.6.4.5 Wrist and hand injuries The following data was collected to find out the prevalence of wrist and hand injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed the participants to wrist and hand injuries as well as the type of injury that they sustained. This is indicated in the tables below.

Table 40: Number of participants who sustained a wrist or hand injury Frequency (n) Percentage (%)

Yes 15 36.6 No 26 63.4 Total 41 100 Missing 14 Total 55

In the sample (n=41), 36.6% of the participants stated that they sustained an injury to their wrist or hand while the remaining 63.4% stated that they had not sustained an injury. This indicates that the majority of the participants had not sustained an injury to their wrist or hand while paddling.

Table 41: Types of wrist or hand injury that the participants sustained Injury Frequency (n) Percentage (%)

Ligamentous sprains 4 28.6 Carpal Tunnel 3 21.4 Overuse 3 21.4 Tendonitis 3 21.4 Muscle strain 1 7.1 Total 14 100

In the sample (n=14), 21.4% of the participants had Carpal Tunnel Syndrome, 28.6% had ligamentous sprains, 7.1% had muscle strains, 21.4% had overuse injuries and 21.4% had tendonitis. The most common wrist or hand injury was ligamentous sprains.

Table 42: Class of water the participants were on when they sustained the wrist or hand injury Frequency (n) Percentage (%)

Class 0 6 50 Class 1 2 16.7 Class 2 1 8.3 Class 3 1 8.3 Class 4 2 16.7 Total 12 100 Missing 3 Total 15

In the sample (n=12), 50% of the participants sustained a wrist or hand injury on a Class 0 waterbody, 16.7% sustained an injury on a Class 1 waterbody, 8.3% sustained an injury on a Class 2 waterbody, 8.3% sustained an injury on a Class 3 waterbody and 16.7% of the participants sustained an injury on a Class 4 waterbody. Most of the participants who sustained a wrist or hand injury were competing or training on a Class 0 waterbody.

Table 43: Age of the participants who sustained a wrist or hand injury Frequency (n) Percentage (%)

18 3 23.1 20 2 15.4 21 1 7.7 30 2 15.4 34 1 7.7 40 2 15.4 45 1 7.7 49 1 7.7 Total 13 100 Missing 2 Total 15

For the 13 participants who sustained a wrist or hand injury, the age range was 18 to 49 years old. In the sample, 23.1% of participants were 18 years old, 15.4% were 20 years old, 7.7% were 21 years old, 15.4%

were 30 years old, 7.7% were 34 years old, 15.4% were 40 years old, 7.7% were 45 years old and 7.7% were 49 years old. The age group with the most frequent wrist or hand injury was 18 years old.

Table 44: Participants who had recurrent wrist or hand injuries Frequency (n) Percentage (%)

Yes 10 76.9 No 3 23.1 Total 13 100 Missing 2 Total 15

In the sample (n=13), 76.9% of the participants stated that their wrist or hand injury was recurrent while the remaining 23.1% stated that it was not recurrent. Most of the participants therefore had recurrent wrist or hand injuries.

Table 45: Participants who received treatment for their hand or wrist injury Frequency (n) Percentage (%)

Yes 6 50 No 6 50 Total 12 100 Missing 3 Total 15

In the sample (n=12), 50% of the participants received treatment for their wrist or hand injury while 50% did not.

Table 46: Cross-tabulation between the category the participants competed in and the wrist or hand injury Cross-tabulation

Q20.5.1 Have you ever Total sustained an injury to your wrist or hand while paddling? Yes No Q15 What Sprinting (200m – n 2 9 11 category do you 5000m) % within Q15 What 18.2% 81.8% 100% compete in? category do you compete in? Marathons (10km – n 8 15 23 100km) % within Q15 What 34.8% 65.2% 100% category do you compete in? Both n 5 2 7 % within Q15 What 71.4% 28.6% 100% category do you compete in? Total n 15 26 41 % within Q15 What 36.6% 63.4% 100% category do you compete in?

In the sample (n=41), 2 of the 11 participants competing in the sprinting category sustained a wrist or hand injury, 8 of the 23 participants competing in the marathon category sustained a wrist or hand injury and 5 of the 7 participants competing in both events sustained a wrist or hand injury. Of the 15 participants who sustained wrist or hand injuries, 8 competed in marathon events. In all the categories, relatively few paddlers sustained wrist or hand injuries. Pearson Chi-Square test revealed a p-value of 0.071, which indicated that there was no statistically significant relationship between the development of a wrist or hand injury and the category that the participants’ competed in.

4.6.4.6 Lower back injuries The following data was collected to find out the prevalence of lower back injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed the participants to lower back injuries as well as the type of injury they sustained. This is shown in the tables below.

Table 47: Number of participants who sustained a lower back injury Frequency (n) Percentage (%)

Yes 20 48.8 No 21 51.2 Total 41 100 Missing 14 Total 55

In the sample (n=41), 48.8% of the participants stated that they had sustained a lower back injury while the remaining 51.2% stated that they had not sustained a lower back injury. The majority of the participants had therefore not sustained a lower back injury.

Table 48: Types of lower back injury that the participants sustained Injury Frequency (n) Percentage (%) Overuse 5 27.8 Muscle strain 4 22.2 Ligamentous sprain 3 16.7 Referred pain 2 11.1 Disc herniation 1 5.6 Scoliosis 1 5.6 Misaligned pelvis 1 5.6 Wound or laceration 1 5.6 Total 18 100

In the sample (n=18), 5.6% of the participants had disc herniations, 16.7% had ligamentous sprains, 22.2% had muscle strains, 27.8% had overuse injuries 11.1% had referred pain, 5.6% had scoliosis, 5.6% had a misaligned pelvis and 5.6% had a wound or laceration. The most common lower back injury was due to overuse.

Table 49: Class of water the participants were on when they sustained the lower back injury Frequency (n) Percentage (%)

Class 0 7 35 Class 1 4 20 Class 2 3 15 Class 3 4 20 Class 4 1 5 Class 6 1 5 Total 20 100

In the sample (n=20), 35% of the participants sustained a lower back injury on a Class 0 waterbody, 20% sustained an injury on a Class 1 waterbody, 15% sustained an injury on a Class 2 waterbody, 20% sustained an injury on a Class 3 waterbody, 5% sustained an injury on a Class 4 waterbody and 5% sustained an injury on a Class 6 waterbody. Most of the participants who sustained an injury to their lower back were competing or training on a Class 0 waterbody.

Table 50: Age of the participants who sustained a lower back injury Frequency (n) Percentage (%)

12 1 5 16 3 15 18 1 5 20 1 5 22 1 5 29 1 5 30 2 10 34 1 5 39 1 5 40 5 25 41 1 5 42 1 5 44 1 5 Total 20 100

For the 20 participants who sustained a lower back injury, the age range was 12 to 44 years old. In the sample, 5% were 12 years old, 15% were 16 years old, 5% were 18 years old, 5% were 18 years old, 5% were 22 years old, 5% were 29 years old, 10% were 30 years old, 5% were 34 years old, 5% were 39 years old, 25% were 40 years old, 5% were 41 years old, 5% were 42 years old and 5% were 44 years old. The age group which most commonly sustained lower back injuries was 40 years old.

Table 51: Participants who had recurrent lower back injuries Frequency (n) Percentage (%)

Yes 16 80 No 4 20 Total 20 100

In the sample (n=20), 80% of the participants stated that their lower back injury was recurrent while the remaining 20% stated that it was not recurrent. Most of the participants therefore had recurrent lower back injuries.

Table 52: Participants who received treatment for their lower back injury Frequency (n) Percentage (%)

Yes 14 70 No 6 30 Total 20 100

In the sample (n=20), 70% of the participants stated that they received treatment for their lower back injury while the remaining 30% stated that they did not. Most of the participants did receive treatment for their lower back injury.

Table 53: Cross-tabulation between the category the participants competed in and the lower back injury Cross-tabulation Q20.6.1 Have you ever sustained Total an injury in/on your lower back while paddling? Yes No Q15 What Sprinting n 6 5 11 category do you (200m – % within Q15 What 54.5% 45.5% 100% compete in? 5000m) category do you compete in? Marathons n 10 13 23 (10km – % within Q15 What 43.5% 56.5% 100% 100km) category do you compete in? Both n 4 3 7 % within Q15 What 57.1% 42.9% 100% category do you compete in? Total n 20 21 41 % within Q15 What 48.8% 51.2% 100% category do you compete in?

In the sample (n=41), 6 of the 11 participants competing in the sprinting category sustained a lower back injury, 10 of the 23 participants competing in the marathon category sustained a lower back injury and 4 of the 7 participants competing in both events sustained a lower back injury. Of the 20 participants who sustained lower back injuries, 10 competed in marathon events. Across all categories, relatively few paddlers sustained lower back injuries. Pearson Chi-Square test revealed a p-value of 0.740, which indicated that there was no statistically significant relationship between the development of a lower back injury and the category that the participants’ competed in.

4.6.4.7 Hip and thigh injuries The following data was collected to find out the prevalence of hip and thigh injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed participants to hip and thigh injuries as well as the type of injury they sustained. This is indicated in the tables below.

Table 54: Number of participants who sustained a hip or thigh injury Frequency (n) Percentage (%)

Yes 5 12.2 No 36 87.8 Total 41 100 Missing 14 Total 55

In the sample (n=41), 12.2% of the participants sustained an injury to their hip or thigh while the remaining 87.8% did not. Most of the participants had not sustained an injury to the hip or thigh.

Table 55: Types of hip or thigh injuries that the participants sustained Injury Frequency (n) Percentage (%)

Muscle strain 2 40 Wound or laceration 1 20 Inflamed cartilage 1 20 Sciatic nerve pain 1 20 Total 5 100

In the sample (n=5), 20% of the participants had a wound or laceration, 40% had a muscle strain, 20% had inflamed cartilage and 20% had sciatic nerve pain. The most common hip and thigh injury among the participants was muscle strains.

Table 56: Cross-tabulation between the category the participants competed in and the hip or thigh injury Cross-tabulation Q20.7.1 Have you ever Total sustained an injury to your hip or thigh while paddling? Yes No Q15 What Sprinting (200m – n 0 11 11 category do you 5000m) % within Q15 What 0% 100% 100% compete in? category do you compete in? Marathons (10km – n 4 19 23 100km) % within Q15 What 17.4% 82.6% 100% category do you compete in? Both n 1 6 7 % within Q15 What 14.3% 85.7% 100% category do you compete in? Total n 5 36 41 % within Q15 What 12.2% 87.8% 100% category do you compete in?

In the sample (n=41), none of the 11 participants competing in the sprinting category sustained a hip or thigh injury, 4 of the 23 participants competing in the marathon category sustained a hip or thigh injury and 1 of the 7 participants competing in both events sustained a hip or thigh injury. Of the 5 participants who sustained hip or thigh injuries, 4 competed in marathon events. Across all the categories, relatively few paddlers sustained hip or thigh injuries. Pearson Chi-Square test revealed a p-value of 0.344, which indicated that there was no statistically significant relationship between the development of a hip or thigh injury and the category that the participants’ competed in.

4.6.4.8 Knee injuries The following data was collected to find out the prevalence of knee injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed participants to knee injuries as well as the injuries which they sustained. This is indicated in the tables below.

Table 57: Number of participants who sustained a knee injury Frequency (n) Percentage (%)

Yes 10 24.4 No 31 75.6 Total 41 100 Missing 14 Total 55

In the sample (n=41), 24.4% of the participants stated that they sustained an injury to their knee while the remaining 75.6% stated that they did not sustain an injury to their knee. Most of the participants therefore did not sustain a knee injury.

Table 58: Types of knee injury that the participants sustained Injury Frequency (n) Percentage (%)

Wound or laceration 4 40 Patellofemoral Pain Syndrome 2 20 Dislocation 1 10 Meniscus injury 1 10 Ligamentous sprain 1 10 Muscle strain 1 10 Total 10 100

In the sample (n=10), 40% of the participants had a wound or laceration, 10% had dislocations, 10% had meniscus injuries, 20% had Patellofemoral Pain Syndrome, 10% had ligamentous sprains and 10% had muscle strains. The most common knee injury was wounds or lacerations.

Table 59: Class of water the participants were on when they sustained the knee injury Frequency (n) Percentage (%)

Class 0 2 22.2 Class 1 2 22.2 Class 3 1 11.1 Class 4 2 22.2 Class 5 2 22.2 Total 9 100 Missing 1 Total 10

In the sample (n=9), 22.2% of the participants sustained a knee injury on a Class 0 waterbody, 22.2% sustained an injury on a Class 1 waterbody, 11.1% sustained an injury on a Class 3 waterbody, 22.2% sustained an injury on a Class 4 waterbody and 22.2% sustained an injury on a Class 5 waterbody. The development of knee injuries was not isolated to one class of waterbody but occurred equally across all the classes.

Table 60: Age of the participants who sustained a knee injury Frequency (n) Percentage (%)

15 1 10 18 2 20 20 2 20 25 1 10 30 2 20 45 1 10 48 1 10 Total 10 100

For the 10 participants who sustained a knee injury, the age range was 15 to 48 years old. In the sample, 10% of the participants were 15 years old, 20% were 18 years old, 20% were 20 years old, 10% were 25 years old, 20% were 30 years old, 10% were 45 years old and 10% were 48 years old. The development of knee injuries was spread evenly across the age groups.

Table 61: Participants who sustained recurrent knee injuries Frequency (n) Percentage (%)

Yes 7 70 No 3 30 Total 10 100

In the sample (n=10), 70% of the participants stated that their knee injury was recurrent while the remaining 30% stated that it was not recurrent. Most of the participants had recurrent knee injuries.

Table 62: Participants who received treatment for their knee injury Frequency (n) Percentage (%)

Yes 5 50 No 5 50 Total 10 100

In the sample (n=10), 50% of the participants received treatment for their injury while the remaining 50% stated that they did not receive treatment.

Table 63: Cross-tabulation between the category the participants competed in and the knee injury Cross-tabulation

Q20.8.1 Have you ever Total sustained an injury to your knee while paddling? Yes No Q15 What Sprinting (200m – n 3 8 11 category do you 5000m) % within Q15 What 27.3% 72.7% 100% compete in? category do you compete in? Marathons (10km – n 5 18 23 100km) % within Q15 What 21.7% 78.3% 100% category do you compete in? Both n 2 5 7 % within Q15 What 28.6% 71.4% 100% category do you compete in? Total n 10 31 41 % within Q15 What 24.4% 75.6% 100% category do you compete in?

In the sample (n=41), 3 of the 11 participants competing in the sprinting category sustained a knee injury, 5 of the 23 participants competing in the marathon category sustained a knee injury and 2 of the 7 participants competing in both events sustained a knee injury. Across all categories, relatively few paddlers sustained knee injuries. Pearson Chi-Square test revealed a p-value of 0.903, which indicated that there was no statistically significant relationship between the development of a knee injury and the category that the participants’ competed in.

4.6.4.9 Ankle and foot injuries The following data was collected to find out the prevalence of ankle and foot injuries in sprinting and marathon kayaking. A comparison was done to find out which event predisposed participants to ankle and foot injuries as well as the type of injury that they sustained. This is indicated in the tables below.

Table 64: Number of participants who sustained an ankle or foot injury Frequency (n) Percentage (%)

Yes 12 29.3 No 29 70.7 Total 41 100 Missing 14 Total 55

In the sample (n=41), 29.3% of the participants stated that they sustained an injury to their ankle or foot while the remaining 70.7% stated that they did not sustain an injury. Most of the participants therefore did not sustain an injury to their ankle or foot.

Table 65: Types of ankle or foot injuries that the participants sustained Injury Frequency (n) Percentage (%)

Wound or laceration 4 33.3 Fractured toes 4 33.3 Ligamentous sprain 4 33.3 Total 12 100

In the sample (n=12), 33.3% of the participants had a wound or laceration, 33.3% had fractured toes and 33.3% had ligamentous sprains.

Table 66: Class of water the participants were on when they sustained the ankle or foot injury Frequency (n) Percentage (%)

Class 0 4 40 Class 1 2 20 Class 3 3 30 Class 6 1 10 Total 10 100 Missing 2 Total 12

In the sample (n=10), 40% of the participants sustained an ankle or foot injury on a Class 0 waterbody, 20% sustained an injury on a Class 1 waterbody, 30% sustained an injury on a Class 3 waterbody and 10% sustained an injury on a Class 6 waterbody. Most of the participants who sustained an injury to their ankle or foot were competing or training on a Class 0 waterbody.

Table 67: Age of the participants who sustained an ankle or foot injury Frequency (n) Percentage (%)

12 1 11.1 16 1 11.1 17 3 33.3 30 1 11.1 40 2 22.2 48 1 11.1 Total 9 100 Missing 3 Total 12

For the 9 participants who sustained an ankle or foot injury, the age range was from 12 to 44 years old. In the sample, 11.1% of the participants were 12 years old, 11.1% were 16 years old, 33.3% were 17 years old, 11.1% were 30 years old, 22.2% were 40 years old and 11.1% were 48 years old. The ankle and foot injuries occurred across all age groups but were slightly more predominant in the 17-year-old age group.

Table 68: Participants who had recurrent ankle or foot injuries Frequency (n) Percentage (%)

Yes 7 63.6 No 4 36.4 Total 11 100 Missing 1 Total 12

In the sample (n=11), 63.6% of the participants stated that their ankle or foot injury was recurrent while the remaining 36.4% stated that their injury was not recurrent. Most of the participants had recurrent ankle or foot injuries.

Table 69: Participants who received treatment for their ankle or foot injury Frequency (n) Percentage (%)

Yes 5 50 No 5 50 Total 10 100 Missing 2 Total 12

In the sample (n=10), 50% of the participants stated that they received treatment for their ankle or foot injury while the remaining 50% stated that they did not receive treatment.

Table 70: Cross-tabulation between the category the participants competed in and the ankle or foot injury

Cross-tabulation Q20.9.1 Have you ever Total sustained an injury to your ankle or foot while paddling? Yes No Q15 What Sprinting (200m – n 4 7 11 category do you 5000m) % within Q15 What 36.4% 63.6% 100% compete in? category do you compete in? Marathons (10km – n 5 18 23 100km) % within Q15 What 21.7% 78.3% 100% category do you compete in? Both n 3 4 7 % within Q15 What 42.9% 57.1% 100% category do you compete in? Total n 12 29 41 % within Q15 What 29.3% 70.7% 100% category do you compete in?

In the sample (n=41), 4 of the 11 participants competing in the sprinting category sustained an ankle or foot injury, 5 of the 23 participants competing in the marathon category sustained an ankle or foot injury and 3 of the 7 participants competing in both events sustained an ankle or foot injury. Across all categories, relatively few paddlers sustained ankle or foot injuries. Pearson Chi-Square test revealed a p-value of 0.467, which indicated that there was no statistically significant relationship between the development of an ankle or foot injury and the category that the participants’ competed in.

4.7 Medical history Data was collected on the participants’ medical history to identify whether they had a chronic medical condition and whether the condition was being treated. This is indicated in the tables below.

Table 71: Participants who had a chronic medical condition Frequency (n) Percentage (%)

Yes 10 18.2 No 45 81.8 Total 55 100

In the sample (n=55), 18.2% of the participants stated that they had a chronic medical condition while the remaining 81.8% stated that they did not. Most of the participants did not have a chronic medical condition.

Table 72: Types of chronic medical conditions that the participants had Frequency (n) Percentage (%)

Asthma 2 20 Cholesterol 2 20 Aortic condition 1 10 Cholesterol, hypertension 1 10 Chronic Fatigue Syndrome 1 10 Eczema 1 10 Epistaxis 1 10 Plates in left arm 1 10 Total 10 100

In the sample (n=10), 10% of the participants had aortic conditions, 20% had asthma, 20% had cholesterol issues, 10% had problems with cholesterol and hypertension, 10% had Chronic Fatigue Syndrome, 10% had eczema, 10% had epistaxis and 10% had plates in their left arm.

Table 73: Participants with a chronic medical condition who were receiving treatment Frequency (n) Percentage (%)

Yes 9 90 No 1 10 Total 10 100

In the sample (n=10), 90% of the participants stated that they received treatment for their chronic medical condition while the remaining 10% stated that they did not. Most of the participants received treatment for their chronic medical condition.

4.8 Chiropractic treatment In this section, data was collected to establish which participants received chiropractic treatment and whether any of the participants would consider seeing a chiropractor. This is indicated in the tables below.

Table 74: Participants who had previously received chiropractic treatment Frequency (n) Percentage (%)

Yes 29 52.7 No 26 47.3 Total 55 100

In the sample (n=55), 52.7% of the participants stated that they had previously received chiropractic treatment while the remaining 47.3% stated that they had not. Most of the participants had previously received chiropractic treatment.

Table 75: Participants who would consider seeing a chiropractor Frequency (n) Percentage (%)

Yes 39 70.9 No 16 29.1 Total 55 100

In the sample (n=55), 70.9% of the participants stated that they had considered seeing a chiropractor while the remaining 29.1% stated that they had not. Most of the participants had considered seeing a chiropractor.

CHAPTER FIVE: DISCUSSION

5.1 Introduction In Chapter 3, the data collection and analysis processes that were used in this study were discussed and in Chapter 4, data analysis results were reported. These results are further discussed in this chapter. The study focused on the following research questions: 1. Does paddling increase the prevalence of musculoskeletal injury development? 2. Is there an increase in the prevalence of musculoskeletal injuries in competitive paddlers who have been competing for a longer period of time? 3. Is there a higher prevalence of musculoskeletal injuries in certain body regions compared to others? 4. Are certain body regions more susceptible to injury in kayakers who compete in marathons, sprinting or both disciplines?

5.2 Prevalence of musculoskeletal injuries in kayakers The study found that 72.5% of the participants had been injured during their paddling career, however, only 23.6% stated that they were predisposed to the development of the injury prior to their paddling career. Table 5.76 below compares this prevalence with other studies conducted amongst competing canoeists and kayakers.

Table 76: Comparison of results from similar studies

Prevalence of Researchers Setting Sample Size Musculoskeletal Injuries n=48 (84.2%) Feher (2009) 2006 Isuzu Berg River 57 Canoe Marathon - Marathon Canoeists n=219 (55.8%) Fiore & Houston (2001) Injuries in whitewater 392 kayaking n=172.36 (62%) Haley & Nichols (2009) A survey of injuries and 278 medical conditions affecting competitive adult outrigger canoe paddlers on O'ahu n=271 (100%) Krupnick, Cox & Summers Injuries sustained during 54 (1999) competitive whitewater paddling: A survey of athletes in the 1996 Olympic trials

The following conclusion excludes the findings of Krupnick et al. (1999) since their study did not calculate the total percentage of participants who were injured. In the present study, the number of injuries that occurred per participant was recorded, which included more than one injury per participant.

The average injury rate calculated from similar studies was 67.3%, with the maximum being 84.2% and the minimum being 55.8%. The 72.5% figure for this study falls within this range. This indicates that the paddlers at Dabulamanzi Canoe Club were exposed to similar conditions and developed musculoskeletal injuries at a similar rate to those from similar studies. This study therefore confirms the trends established in similar studies.

Comparing this study to the one conducted by Feher in 2009, the occurrence of musculoskeletal injuries in marathon kayakers in 2006 was significantly higher than the number of injuries reported in this study. The results may be similar due to similar paddling techniques used in South African kayaking. Further data would need to be collected to establish whether the members at Dabulamanzi also compete in the Isuzu Berg River

Canoe Marathon and what the injury rate is for those participants. Only then could an adequate comparison be made as all waterbody conditions are different and require different skill sets.

5.3 Research Question 1 discussion Does paddling increase the prevalence of musculoskeletal injury development? Data was collected to establish the number of participants who developed musculoskeletal injuries and whether these participants were predisposed to any of these musculoskeletal injuries prior to commencing their kayaking career.

This study found that 72.5% of the participants developed a musculoskeletal injury during their paddling career. In the sample, 23.6% of the participants stated that they had been predisposed to the injury prior to commencing their paddling career while the remaining 76.4% stated that they were not predisposed. These findings indicate that most of the paddlers developed injuries during their paddling career and had not been predisposed to these musculoskeletal injuries prior to their paddling career. It can therefore be concluded that kayaking increased the risk of musculoskeletal injuries in the athletes.

The above findings are similar to those of Feher (2009), who found that 84.2% of the participants sustained one or more injuries during the race. It was noted by Feher, that 52.2% of the participants had had previous surgical interventions, although 71.0% of the participants reported no pre-existing medical conditions. This study therefore confirms the findings of Feher (2009).

The present study also confirms the findings of Krupnick et al. (1999), who stated that minor musculoskeletal injuries were the most prevalent although there was a 20% risk of severe injury.

The study done conducted by Haley and Nichols (2009) found that 62.0% of the participants had experienced paddling-related musculoskeletal injuries, however, only 10% reported a prior history of medical conditions. The findings of the present study therefore enhance the viability of the study conducted by Haley and Nichols (2009).

This study noted that there was a trend between the development of an injury and the class of water that the participants competed on. It was noted that the majority of musculoskeletal injuries that were reported occurred in participants who competed on a class 0 waterbody. This finding may be as a result of more participants taking part in events that take place on this waterbody. The participants who took part in this study trained and took part in events that took place on this class of waterbody. As a result, these participants may not be exposed to other waterbody classes as readily as participants from other research studies. This 82

may be the reason why this finding was different from that of the previous studies. Previous studies indicated that more injuries were reported in participants who competed on more technical waterbody classes.

5.4 Research Question 2 discussion Is there an increase in the prevalence of musculoskeletal injuries in competitive paddlers who have been competing for a longer period of time? The study sought to find if the number of years an athlete had been paddling increased the risk of musculoskeletal injury. Data collected made it possible to perform this comparison. Pearson’s correlation (p=0.702) indicated that there was no significant relationship between the number of years that a participant had been paddling and the occurrence of musculoskeletal injury. A larger sample group is needed to establish whether this correlation is valid for this sample group and the kayaking community as an entirety.

The findings of the present study are inconclusive with regard to those of Haley and Nichols (2009), who reported that a lack of conditioning, experience and proper technique resulted in more injuries and that the occurrence of injury increased as participants increased their training or participated in the additional long- distance paddling season. The findings of the present study did not focus on training methods and habits. Further research would be needed to establish if there is a link between training methods and injury development.

5.5 Research Question 3 discussion Is there a higher prevalence of musculoskeletal injuries in certain body regions compared to others? The study gathered data to establish whether certain body regions were at risk of developing more musculoskeletal injuries than others. Data was gathered on the following regions: the head, neck, shoulders, elbows, wrists/hands, lower back, hips/thighs, knees and ankles/feet.

In the sample, 17.5% were head injuries, 15% were neck injuries, 60% were shoulder injuries, 22.5% were elbow injuries, 37.5% were wrist/hand injuries, 50% were lower back injuries, 12.5% were hip/thigh injuries, 25% were knee injuries and 30% were ankle/foot injuries. This study established that there was a higher prevalence of injury in the shoulders (60%), lower back (50%), wrists/hands (37.5%), ankles/feet (30%), knees (25%) and elbows (22.5%).

These findings concur with previous studies (Feher, 2009; Fiore, 2003, Krupnick et al., 1999; Haley & Nichols, 2009).

In this study, 60% of the participants reported shoulder girdle injuries. Similarly, Krupnick et al. (1999) reported a 20% incidence of shoulder injuries, Feher (2009) reported a 17.1% incidence and Haley and Nichols (2009) reported a 40% incidence in canoeists/kayakers. Feher (2009) theorised that shoulder injuries occurred in kayaking due to the repetitive action of the shoulder joint, leading to possible microtrauma of the rotator cuff tendon. It has been hypothesised that during repetitive canoeing strokes, there may be enlargement of the supraspinatus muscle or tendon, the long head of the biceps or the subacromial bursa within the subacromial space. This may result in a mechanical impingement described as ‘paddlers shoulder’ (Pelham, Holt & Stalker, 1995).

Fiore and Houston (2001) suggested that lumbar spine injuries occurred frequently amongst kayakers owing to the sequence of repetitive movements around the fulcrum of the lumbar spine. Fiore and Houston (2001) reported a 31% incidence of lumbar injuries − a lower figure than the 50% incidence of lumbar injuries in the current study. Similarly, Haley and Nichols (2009) reported a 26% incidence while Feher (2009) reported an 11.4% incidence for lumbar injuries. This study has the highest incidence of lower back injuries, which may possibly be due to the inclusion of sprinting, marathon and kayakers who compete in both disciplines.

Du Toit et al. (1999) reported wrist and elbow injuries as common areas of injury in marathon canoeists. An average incidence of 23% was reported in South African kayakers (Du Toit et al., 1999). Feher (2009) reported a 7.9% incidence for elbow and forearm injuries and a 6.4% incidence of wrist injuries. The current study established a 37.5% incidence of wrist and hand injuries and a 22.5% incidence of elbow injuries. Du Toit et al. (1999) suggested that the repetitive nature of the elbow and wrist flexion and extension, combined with an almost constant concentric flexor grip during the kayaking stroke, may contribute to the development of elbow, forearm and wrist injuries (Du Toit et al., 1999).

Haley and Nichols (2009) reported a 3.8% incidence of knee injuries and a 2.7% incidence of ankle injuries. The current study established a 30% incidence for ankle/foot injuries and a 25% incidence of knee injuries. The most commonly reported ankle/foot injuries were wounds and lacerations, fractured toes and ligamentous sprains. The most commonly reported knee injuries were wounds and lacerations and Patellofemoral Pain Syndrome. These injuries occurred when the participants were completing their portage. Participants opted for portage if the water conditions were too poor or if the water level was too low. The participants would have to carry their kayak to the next entry point on the waterbody. This study has a much higher incidence rate of ankle/foot and knee injuries compared to the findings reported by Haley and Nichols (2009). This may be due to the greater number of marathon kayakers and the lack of outrigger canoeists.

5.6 Research Question 4 discussion Are certain body regions more susceptible to injury in kayakers who compete in marathons, sprinting or both disciplines? The study gathered data to establish whether kayakers who competed in the different kayaking disciplines were more susceptible to musculoskeletal injuries in certain body regions more than others. The data gathered in this study is discussed below.

No statistically significant relationship between the body injury and the kayaking discipline that the participants could be established. This occurred because there were too many expected counts in the contingency tables being less than 5 and therefore did not meet the mathematical assumption with which to perform chi-squared tests for independence. Thus, no reference could be made for the general kayaking population, but a general trend was noted in this study. This trend established that the participants who competed in the marathon discipline sustained a higher injury rate than those who competed and trained in the other disciplines. The injuries that were recorded occurred more readily in the elbow and hand/wrist regions. The occurrence of these injuries may be due to overtraining, altered biomechanics or incorrect paddling technique.

5.7 Conclusion The study found that 72.5% of the participants had been injured while kayaking and 23.6% of the participants stated that they were pre-disposed to the development of the musculoskeletal injury. This indicates that the majority of the participants had sustained a musculoskeletal injury with no prior disposition to the injury before commencing their paddling career. The reported incidence rate for this study accords with previous injury reports on similar topics. In contrast to Haley and Nichols (2009), this study reported that there was no significant link between the amount of years the participants had been competing and the rate of injury. However, this study does corroborate the injury findings of Haley and Nichols (2009). The present study and previous studies have indicated that the shoulders, lower back, wrists/hands, ankles/feet, knees and elbows were the most commonly injured regions of the body. The injuries in these regions were most commonly wounds and lacerations, ligamentous sprains, muscle strains, overuse injuries and fractures. The general trend noted for injury occurrence was that participants who competed in marathons were more likely to sustain injuries. This may be due to overtraining, overuse or altered biomechanics. A larger sample group would be required to establish whether this finding is plausible.

CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS

6.1 Introduction This study aimed to determine the prevalence of musculoskeletal injuries in competitive paddlers at Dabulamanzi Canoe Club, with the intention of identifying whether certain body regions were more susceptible to injury in marathon kayakers, sprint kayakers or kayakers who competed in both disciplines. The study drew a sample of 55 participants in order to address the following research questions: 1. Does kayaking increase the risk of musculoskeletal injury development? 2. Is there an increase in the prevalence of musculoskeletal injuries in competitive paddlers who have been competing for a longer period of time? 3. Is there a higher prevalence of musculoskeletal injuries in certain body regions compared to others? 4. Are certain body regions more susceptible to injury in kayakers who compete in marathons, sprinting or both disciplines?

In conclusion, the study successfully answered its four research questions and met its objectives. The study concluded that kayakers at Dabulamanzi Canoe Club were exposed to an increased risk of musculoskeletal injury. There was no statistically significant relationship between the number of years the kayakers had been paddling and the development of the musculoskeletal injury. Certain body parts were exposed to an increased injury rate. These body regions included the shoulders, lower back, wrists/hands, ankles/feet, knees and elbows, with the shoulders and lower back having the highest prevalence. With such high musculoskeletal injury prevalence levels, there is an urgent need to introduce various interventions to lower the risk of injury. There was no statistically significant relationship between the development of an injury and the discipline that the participants took part in. A trend was established between injury development in the elbow and hand/wrist regions and the marathon discipline. There is also a need for further research to gain a greater understanding of the mechanisms behind injury development in competitive kayakers. This study was able to provide reliable, quantifiable information on the prevalence of musculoskeletal injuries in competitive paddlers at Dabulamanzi Canoe Club. The data obtained from this study had previously been lacking in South Africa. This research was important as it enhanced the validity and reliability of previous, outdated research.

6.2 Recommendations In response to the above findings, the following recommendations are made: • As it was noted that kayakers have a higher risk of development of musculoskeletal injury, adequate management and support programmes should be introduced. These could include:

o Kayaker education o Training programmes o Chiropractic support • It was noted that shoulder and lower back injuries were the most prevalent injuries in kayaking. Adequate preventative measures and support programmes should be introduced. These could include: o Training programmes o Correct kayaking ergonomics o Chiropractic support • Marathon kayakers should be encouraged to incorporate a stretching and strengthening programme into their daily training, primarily focusing on their forearms and wrists. This is recommended as it was noted in this study and in the literature that marathon kayakers had a higher prevalence of elbow and wrist/hand injuries such as tendonitis. • Kayakers who take part in both disciplines need to be conscious of their training programmes so that they do not over-train. This is recommended as it was noted in this study that participants who took part in both disciplines sustained musculoskeletal injuries at a higher rate.

6.3 Recommendations for further studies The following research directions are recommended as a way of building upon the present study on the musculoskeletal injuries affecting competitive paddlers at Dabulamanzi Canoe Club: • A study using a larger sample size to increase the validity of the study. • A study using a larger sample size to verify whether there is a statistically significant relationship between the development of elbow and hand/wrist injuries in marathon kayakers. • A study with a questionnaire that focuses more specifically on training programmes and the occurrence of the specific injuries. • Experimental studies that identify the cause and effect of shoulder and lower back injuries in competitive paddlers. • Future investigation to determine if technique alterations in response to different stroke rates are likely to increase or reduce the risk of developing musculoskeletal injuries in kayakers. • The effectiveness of various interventions including chiropractic support in reducing shoulder and lower back injuries among competitive paddlers.

REFERENCES

Altfather, K. & Peterson, C. (2012). Kayak capsize recovery system. United States Patent Application Publication, 1(1): 1-18.

American Heritage Dictionary of the English Language. (2011). 5th edition. Sv. ‘paddler’. Available from: https://www.thefreedictionary.com/paddler. Last accessed: 15th of March 2020.

Anderson, K., Strickland, S.M. & Warren, R. (2001). Hip and groin injuries in athletes. The American Journal of Sports Medicine, 29(4): 521-533.

Arya, R.K. & Jain, V. (2013). Osteoarthritis of the knee joint: An overview. Journal, Indian Academy of Clinical Medicine, 14(2): 154-162.

Bawazeer, A. & Goel, A. (2020a). Anterior cruciate ligament. Available from: Anatomy of normal human anterior cruciate ligament attachments evaluated by divided small bundles. Last accessed: 20th of March 2020.

Bawazeer, A. & Goel, A. (2020b). Posterior cruciate ligament. Available from: https://radiopaedia.org/articles/posterior-cruciate-ligament?lang=us. Last accessed: 20th of March 2020.

Begon, M., Colloud, F. & Sardain, P. (2010). Lower limb contribution in kayak performance: Modelling, simulation and analysis. Multibody System Dynamics, 23(1): 387-400.

Brockett, C.L. & Chapman, G.J. (2016). Biomechanics of the ankle. Orthopaedics and Trauma, 30(3): 232- 238.

Brown, M.B., Lauder, M. & Dyson, R. (2010). Activation and contribution of trunk and leg musculature to force production during on-water sprint kayaking performance. Proceedings of the 28th Conference of the International Society of Biomechanics Sports, 1(1): 712-713.

Butt, A.M., Gill, C., Demerdash, A., Watanabe, K., Loukas, M., Rozzelle, C.J. & Tubbs, R.S. (2015). A comprehensive review of the sub-axial ligaments of the vertebral column: Part I anatomy and function. Child’s Nervous System, 31(1): 1037-1059.

Canoeing South Africa. (2012). Safety Booklet. Online. Available from: http://www.gcu.co.za/wp- content/uploads/2014/06/CSA-Safety-Booklet-Mar-2012.pdf. Last accessed: 10th of February 2020.

Canoeing South Africa. (2020). Disciplines. Online. Available from: http://www.canoesa.org.za/portfolio/canoe-marathon/. Last accessed: 10th of February 2020.

Chivers, M.D. & Howitt, S.D. (2009). Anatomy and physical examination of the knee menisci: A narrative review of the orthopaedic literature. The Journal of the Canadian Chiropractic Association, 53(4): 319-333.

Cryer, A. (2014). Canoe sprint explained. Online. Available from: http://everything.explained.today/Canoe_sprint.html. Last accessed: 1st of November 2019.

Dabulamanzi Canoe Club. (2020). Home. Online. Available from: http://dabulamanzi.co.za/. Last accessed: 11th of February 2020. du Toit, P., Sole, G., Bowerbank, P. & Noakes, T. D. (1999). Incidence and cause of tenosynovitis of the wrist extensors in long distance paddle kayakers. British Journal of Sports Medicine, 33(1): 105-109.

Espregueira-Mendes, J., & Vieira da Silva, M. (2006). Anatomy of the lateral collateral ligament: A cadaver and histological study. Knee Surgery, Sports Traumatology, Arthroscopy, 14(1): 221-228.

Faber, J. & Fonseca, L.M. (2014). How sample size influences research outcomes. Dental Press Journal of Orthodontics, 19(4):27-29.

Feher, R. (2009). The epidemiology of injuries sustained by kayakers during the 2006 Isuzu Berg River canoe marathon (Masters dissertation). Cape Town: University of Cape Town. Available from: https://open.uct.ac.za/bitstream/item/2785/thesis_hsf_2009_feher_r.pdf?sequence=1. Last accessed: 29th of June 2020.

Fiore, D. (2003). Injuries associated with whitewater rafting and kayaking. Wilderness and Environmental Medicine, 14(1): 255-260.

Fiore, D. & Houston, J. (2001). Injuries in whitewater kayaking. British Journal of Sports Medicine, 35(1): 235- 241.

Fisher, J. (2015). Revealing complexities within flat-water kayaking: Injury prevention and biomechanical analysis (Doctoral thesis). Cape Town: University of Cape Town. Available from: https://open.uct.ac.za/handle/11427/16522. Last accessed: 29th of June 2020.

Galbusera, F., van Rijsbergen, M., Ito, K., Huyghe, J., Brayda-Bruno, M. & Wilke, H.J. (2014). Ageing and degenerative changes of the intervertebral disc and their impact on spinal flexibility. European Spine Journal, 23(3): S324-S332.

Gauteng Canoe Union (GCU). (2014). Sprints. Available from: https://www.gcu.co.za/disciplines/80-2/.html. Last accessed: 11th of February 2020.

Gharries, H. (2018). Clinical anatomy of the spine for pain interventions. Journal of Anesthesia & Critical Care: Open Access, 10(4): 140-145.

Ghasemi-rad, M., Attaya, H., Lesha, H., Vegh, A., Maleki-Miandoab, T., Nosair, E., Sepehrvand, N., Davarian, A., Rajebi, H., Pakniat, A., Fazeli, S.A. & Mohammadi, A. (2015). Ankylosing spondylitis: A state of the art factual backbone. World Journal of Radiology, 7(9): 236-252.

Gomes, B. (2015). Biomechanical determinants of kayak paddling performance in single-seat and crew boats (Doctoral thesis). Porto: University of Porto.

Haley, A. & Nichols, A. (2009). A survey of injuries and medical conditions affecting competitive adult outrigger canoe paddlers on O'ahu. Hawaii Medical Journal, 68(7): 162-165.

Harner, C.D., Vogrin, T.M & Woo, S.L. (2001). Anatomy and biomechanics of the posterior cruciate ligament. Posterior Cruciate Ligament Injuries, 1(1): 3-22.

Hawkes, A.H., Alizadehkhaiyat, O., Fisher, A.C., Kemp, G.J., Roebuck, M.M. & Frostick, S.P. (2011). Normal shoulder muscular activation and co-ordination during a shoulder elevation task based on activities on daily living: An electromyographic study. Journal of Orthopaedic Research,30(1): 53-60.

International Canoe Federation. (2018). Canoe Sprint. Available from: https://www.canoeicf.com/discipline/canoe-sprint.html. Last accessed: 20th of February 2020.

Jain, A. & Clamp, K. (2020). Adult hip pain. InnovAiT, 13(1): 21-27. 90

Jaworski, L., Karpinski, R. & Dobrowolska, A. (2016). Biomechanics of the upper limb. Journal of Technology and Exploitation in Mechanical Engineering, 2(1): 53-59.

Jean-Baptiste, J. (2009). Sprinter vs distance runner. Available from: https://healthyliving.azcentral.com/sprinter-vs-distance-runner-6226.html. Last accessed: 20th of November 2019.

Kazemi, M., Dabiri, Y. & Li, L.P. (2013). Recent advances in computational mechanics of the human knee joint. Computational and Mathematical Methods in Medicine, 1(1): 1-27.

Krupnick, J., Cox, R. & Summers, R. (1998). Injuries sustained during competitive white-water paddling: A survey of athletes in the 1996 Olympic trials. Wilderness and Environmental Medicine, 9(1): 14-18.

Kurutz, M. (2010). Finite element modelling of the human lumbar spine. Finite Element Analysis: Biomedical Applications to Industrial Developments, 1(1): 209-237.

Leardini, A., O’Connor, J.J., Catani, F. & Giannini, S. (2000). The role of passive structures in the mobility and stability of the human ankle joint: A literature review. Foot & Ankle International, 21(7): 602-615.

Lepera, C. (2010). The prevalence of shoulder pain in professional male wheelchair basketball players in Gauteng, South Africa (Unpublished doctoral thesis). Johannesburg: University of Witwatersrand.

Martin, S. & Sanchez, E. (2013). Anatomy and biomechanics of the elbow joint. Seminars in Musculoskeletal Radiology, 17(5): 429-436.

Nigam, Y., Knight, J. & Jones, A. (2009). The physiological effects of bed rest and immobility – Part 3. Nursing Times, 105(23): 18-22.

Olympic Games. (2020). Canoe Sprint. Available from: https://www.olympic.org/canoe-sprint. Last accessed: 20th of February 2020.

Omoumi, P., Teixeira, P., Lecouvet, F. & Chung, C.B. (2010). Glenohumeral joint instability. Journal of Magnetic Resonance Imaging, 33: 2-16.

Panchbhavi, V.K. (2015). Foot bone anatomy. Medscape Online. Available from: https://emedicine.medscape.com/article/1922965-overview. Last accessed: 21st of March 2020.

Pelham, T.W., Holt, L.E. & Stalker, R.E. (1995). The etiology of paddler's shoulder. Australian Journal of Science and Medicine in Sport, 27(2): 43-47.

Statpac Inc. (2014). Survey Design Tutorial. Available from: http://www.statpac.com/surveys/. Last accessed: 2nd of March 2020.

Tarnita, D., Boborelu, C., Popa, D., Tarnita, C. & Rusu, L. (2010). The three-dimensional modelling of the complex virtual human elbow joint. Romanian Journal of Morphology and Embryology, 51(3): 489-495.

Tecklenburg, K., Dejour, D., Hoser, C. & Fink, C. (2006). Bony and cartilaginous anatomy of the patellofemoral joint. Knee Surgery, Sports Traumatology, Arthroscopy, 14(1): 235-240.

Van der Meijden, O.A., Westgard, P., Chandler, Z., Gaskill, T.R., Kokmeyer, D. & Millett, P.J. (2012). Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines. The International Journal of Sports Physical Therapy, 7(2): 197-218.

Viviers, W. (2006). Paddle grip: Handgrip size ratio and associated factors contributing to the development of lateral elbow tendinosis and DeQuervains tenosynovitis in K1 marathon paddlers during the 2006 Berg River Canoe Marathon (Mater’s dissertation). Cape Town: University of Cape Town. Available from: https://open.uct.ac.za/handle/11427/12115. Last accessed: 30th of June 2020. von Braun, S., Frenzel, P., Kding, C. & Fuchs, M. (2020). Utilising mask R-CNN for waterline detection in canoe sprint video analysis. Leipzig University of Applied Sciences, 1(1): 1-10.

Wassinger, C. (2007). Biomechanical and physical characteristics of whitewater kayakers with and without shoulder pain. University of Pittsburgh, School of Health and Rehabilitation Science, 1(1): 1-137.

Westerman, R.W. & Porter, K. (2007). Ankle fractures in adults: An overview. Trauma, 9(1): 267-272.

Wright, W.G., Ivanenko, Y.P. & Gurfinkel, V.S. (2011). Foot anatomy specialization for postural sensation and control. Journal of Neurophysiology, 107(1): 1513-1521.

Wymenga, A.B., Kats, J.J., Kooloos, J. & Hillen, B. (2006). Surgical anatomy of the medial collateral ligament and the posteromedial capsule of the knee. Knee Surgery, Sports Traumatology, Arthroscopy, 14(1): 229- 234.

Yasuda, K., van Eck, C.F., Hoshino, Y., Fu, F.H. & Tashman, S. (2011). Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 1. The American Journal of Sports Medicine, 39(8): 1789-1799.

Zaffagnini, S., Signorelli, C., Bonanzinga, T., Lopomo, N., Raggi, F., Sarsina, T.R.D., Grassi, A., Muccioli, G.M.M. & Marcacci, M. (2016). Soft tissues contribution to hip joint kinematics and biomechanics. Hip International, 26(1): S23-S27.

Appendix A: Permission Letter from Dabulamanzi Canoe Club

Appendix B: Ethical Clearance Letter

Appendix C: Higher Degrees Committee Permission Letter

Appendix D: Adapted Musculoskeletal Questionnaire

Requirements to take part in this study: 1. Are you between the ages of 18 and 50? Ο Yes Ο No 2. Are you a registered competitive member at Dabulamanzi Canoe Club? Ο Yes Ο No 3. Are you a registered competitive member with the Gauteng Canoe Union? Ο Yes Ο No 4. Do you paddle at least twice a week? Ο Yes Ο No

Personal Information: 5. Gender: ο Female ο Male ο Other 6. Age: 7. Height (centimetres): Weight (kilograms): 8. Occupation/ Type of Work:

Paddling Career: 9. How many years have you been paddling? 10. How many years have you been an active competitive member at Dabulamanzi Canoe Club?

11. Number of hours per week you spend doing the following activities (on average): Question Activity 0 1-3 4-6 7-9 10-12 13-15 16-20 21-30 More than 30 11.1 Competing in paddling events 11.2 Training on the dam 11.3 At gym 11.4 Recreating (playing another sport) 11.5 Watching TV 11.6 At work 11.7 At a computer

12. How many days a week do you paddle on the dam? Ο 1 day a week Ο More than 1 day a week 13. List any other sports you take part in and the level at which you participate (e.g. Tennis - Social/ Provincial/ National):

14. What event to you compete in? (Mark all applicable) • Kayak events: ο Single ο Double ο Three ο Four

15. What category do you compete in? (Mark all applicable) Ο Sprinting (200meters – 5000meters) Ο Marathons (10km – 100km) Ο Both 16. Name the kayak(s) that you compete in most often (e.g. Nelo / Jacana):

17. How stable is/are the kayak(s) that you compete in most often? (Mark as applicable) Ο Stable Ο Intermediate Ο Unstable 18. Please complete the following table on the paddling conditions that you compete in. (Mark all applicable) What class of river do you compete on? (Mark all What kayak do you use most often when you paddle How stable is the kayak that you use in these applicable) in your applicable class? (e.g. Nelo / Jacana) conditions? (Mark all applicable) Ο Class 0 – Flat stationary water o Stable o Intermediate o Unstable Ο Class 1 – Moving water with small waves o Stable o Intermediate o Unstable

100

Ο Class 2 – Easy rapids with waves up to a metre o Stable high o Intermediate o Unstable Ο Class 3 – Rapids with high irregular waves o Stable o Intermediate o Unstable Ο Class 4 – Long difficult rapids with constricted o Stable passages o Intermediate o Unstable Ο Class 5 – Extremely difficult, long and very violent o Stable rapids o Intermediate o Unstable Ο Class 6 – For teams of experts only o Stable o Intermediate o Unstable

19. Have you been injured while paddling? Ο Yes Ο No

101

20. Have you ever sustained an injury in any of the following regions while paddling? Please indicate what If “Yes” please indicate what injury you have sustained in Age at What class of water Has this injury Have you region in the body your the region. (e.g. sprain) the time were you paddling on been recurrent? received any injury is in. of injury when you sustained treatment for this (in years) this injury? injury? Head o Class 0 o Yes o Yes Ο o Class 1 o No o No o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Neck o Class 0 o Yes o Yes Ο o Class 1 o No o No o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Shoulders o Class 0 o Yes o Yes Ο o Class 1 o No o No

102

o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Elbows o Class 0 o Yes o Yes Ο o Class 1 o No o No o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Wrists and Hands o Class 0 o Yes o Yes Ο o Class 1 o No o No o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Lower Back o Class 0 o Yes o Yes Ο o Class 1 o No o No

103

o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Hips and Thighs o Class 0 o Yes o Yes Ο o Class 1 o No o No o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Knees o Class 0 o Yes o Yes Ο o Class 1 o No o No o Class 2 o Class 3 o Class 4 o Class 5 o Class 6 Ankles and Feet o Class 0 o Yes o Yes Ο o Class 1 o No o No

104

o Class 2 o Class 3 o Class 4 o Class 5 o Class 6

21. Do you think you were pre-disposed to any of these injuries prior to your paddling career? Ο Yes Ο No 22. Do you have a chronic medical condition? Ο Yes Ο No 23. If “Yes”, please specify: 24. Is this condition being treated? Ο Yes Ο No 25. Have you ever received chiropractic treatment? Ο Yes Ο No 26. Have you ever considered seeing a chiropractor? Ο Yes Ο No

105

Appendix E: Information Letter

DEPARTMENT OF CHIROPRACTIC RESEARCH STUDY INFORMATION LETTER REC 11.0

Date:

Good Day

My name is Bryony Rous. I WOULD LIKE TO INVITE YOU TO PARTICIPATE in a research study on the muscle and bone injuries affecting competitive paddlers at Dabulamanzi Canoe Club.

The study is part of a research project being completed as a requirement for a Master’s Degree in Technology, Chiropractic through the University of Johannesburg, to determine which types of muscle and bone injuries occur most frequently in competitive paddlers at Dabulamanzi Canoe Club.

Before you decide on whether to participate, I would like to explain to you why the research is being done and what it will involve for you. The information letter needs to be read beforehand. You may contact me with any queries and I will go through the information letter with you and answer any questions you have. The questionnaire will be done in your own time and should take about 10 to 20 minutes.

Below, I have compiled a set of questions and answers that I believe will assist you in understanding the relevant details of participation in this research study. Please read through these. If you have any further questions, I will be happy to answer them for you.

1. DO I HAVE TO TAKE PART? No, you don’t have to. It is up to you to decide to participate in the study.

Participant Initials:_____ 106 Version 3.1: Approved 26 July 2018 Author: Prof. C. Stein

2. WHAT EXACTLY WILL I BE EXPECTED TO DO IF I AGREE TO PARTICIPATE? You will have to sign and submit the consent form when you agree to take part in the study. After this, you will have to fill out a questionnaire, which will ask you questions about your paddling habits and if you have sustained any injuries during your paddling career.

3. APPROXIMATELY HOW LONG WILL MY PARTICIPATION TAKE? It will take approximately 10 to 20 minutes for you to complete the survey.

4. WHAT WILL HAPPEN IF I WANT TO WITHDRAW FROM THE STUDY? If you decide to participate, you are free to withdraw your consent at any time without giving a reason and without any consequences, prior to the submission of the questionnaire. Beyond this point withdrawal of consent is not possible due to the anonymous nature of the research.

5. IF I CHOOSE TO PARTICIPATE, WHAT ARE THE RISKS INVOLVED? There are no anticipated risks associated with filling in the online questionnaire.

6. IF I CHOOSE TO PARTICIPATE, WHAT ARE THE BENEFITS INVOLVED? There are no direct benefits to you. Your participation will help us to better understand which injuries commonly affect paddlers and how these injuries could potentially be prevented from occurring in future paddlers.

7. WILL MY PARTICIPATION IN THIS STUDY BE KEPT CONFIDENTIAL? All reasonable efforts will be made to keep your personal information confidential and respect your right to privacy. This questionnaire will be constructed on My Echo. This will allow you to fill in the questionnaire in the comfort of your own home. Once you submit your results, they will be completely anonymous as a randomised code is sent to me with your submission. You are free to withdraw your consent prior to the submission of the data, however, beyond this point withdrawal is not possible due to the anonymous nature of the research.

8. WHAT WILL HAPPEN TO THE RESULTS OF THE RESEARCH STUDY? The results will be written into a research report that will be assessed. In some cases, results may also be published in a scientific journal. In either case, you will not be identifiable in any documents, reports or publications. You will be given access to the results of this if you would like to see them, by contacting me.

Participant Initials:_____ 107 Version 3.1: Approved 26 July 2018 Author: Prof. C. Stein 9. WHAT WILL YOUR RESPONSIBILITIES BE, AS THE RESEARCHER? As the researcher, I will be responsible for keeping your information safe and private. I will only use this information for my research disclosed in this document and I will not share it with any third parties. I will give you feedback on the results obtained in this study and access to the results if you would like to see them.

10. WHO IS ORGANISING AND FUNDING THIS RESEARCH STUDY? The study is being organised by me, under the guidance of my research supervisor at the Department of Chiropractic at the University of Johannesburg. All costs will be covered by the Supervisor linked bursary.

11. WHO HAS REVIEWED AND APPROVED THIS STUDY? Before this study was allowed to start, it was reviewed in order to protect your interests. This review was done first by the Department of Chiropractic, and then secondly by the Faculty of Health Sciences Research Ethics Committee at the University of Johannesburg. In both cases, the study was approved.

12. ARE THERE ANY CONFLICTS OF INTEREST PERTAINING TO THIS STUDY? There are no conflicts of interest held by anyone involved in this study.

13. WHAT IF THERE IS A PROBLEM? If you have any concerns or complaints about this research study, its procedures or risks and benefits, you should ask me. You should contact me at any time if you feel you have any concerns about being a part of this study. My contact details are:

Bryony Rous [email protected]

You may also contact my research supervisor: Dr Fatima Ismail [email protected]

If you feel that any questions or complaints regarding your participation in this study have not been dealt with adequately, you may contact the Chairperson of the Faculty of Health Sciences Research Ethics Committee at the University of Johannesburg:

Participant Initials:_____ 108 Version 3.1: Approved 26 July 2018 Author: Prof. C. Stein Prof. Christopher Stein Tel: 011 559-6564 Email: [email protected]

FURTHER INFORMATION AND CONTACT DETAILS: Should you wish to have more specific information about this research project information, have any questions, concerns or complaints about this research study, its procedures, risks and benefits, you should communicate with me using any of the contact details given above.

Researcher:

Bryony Rous

Participant Initials:_____ 109 Version 3.1: Approved 26 July 2018 Author: Prof. C. Stein Appendix F: Consent Form

DEPARTMENT OF CHIROPRACTIC RESEARCH CONSENT FORM REC 11.0

Prevalence of the musculoskeletal injuries affecting competitive paddlers at Dabulamanzi Canoe Club.

Please initial each box below:

I confirm that I have read and understood the information letter dated for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.

I understand that my participation is voluntary and that I am free to withdraw from this study at any time without giving any reason and without any consequences to me.

I agree to participate in the above research.

Name of Participant Signature of Participant Date

Name of Researcher Signature of Researcher Date

Participant Initials:_____ 110 Version 3.1: Approved 26 July 2018 Author: Prof. C. Stein Appendix G: Statistician Agreement Letter

111

Appendix H: Turnitin Originality Report

112