Upper Extremity Pain Seen With Fly-Casting Technique: A Survey of Fly-Casting Instructors

Wilderness and Environmental Medicine, 15, 267 273 (2004) ORIGINAL RESEARCH Upper Extremity Pain Seen With Fly-Casting Technique: A Survey of Fly-Casting Instructors Timothy J. McCue, MD; Clare E. Guse, MS; Rania L. Dempsey, MD, MS From the Curry Health Center, The University of Montana, Missoula, MT (Dr McCue); and the Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI (Ms Guse and Dr Dempsey). Objective. To identify the prevalence of upper extremity pain symptoms in fly-casting instructors and examine the association between pain and casting style and equipment. Methods. We used a cross-sectional survey of a randomly selected group of 577 fly-casting instructor mailing-list members and recorded equipment; casting styles; pain symptoms; and Disability of the Arm, Shoulder, and Hand inventory. We used univariate statistical tests to examine the associations between pain and casters equipment and styles. Results. In 292 usable surveys, pain was reported in the shoulder (50%), elbow (39%), and wrist (36%) of those surveyed and was characterized as moderate-to-severe by 25% of all respondents. Overhead casting was associated with less frequent wrist and elbow pain than was sidearm or elliptical casting. Respondents who used multiple casting styles had significantly less elbow pain than did single-style casters (7% vs 38% overhead, P.04; 45% sidearm, P.02; 71% elliptical, P.003). Pain was significantly more frequent in those who cast with a haul (75% vs 33%, P.04), used shooting heads (79% vs 66%, P.04), or added weight to sinking flies (78% vs 60%, P.01). Moderate-to-severe pain was more frequent in fishers of heavy saltwater fish. Conclusions. Upper extremity pain was frequent, but not often severe, in this group of fly-casting instructors. Increased weight on the line and haul technique appeared to increase pain symptoms. Modifications in casting style and equipment may help in avoiding or reducing pain. Key words: upper extremity, cumulative trauma disorders, sports injuries, fishing, fly casting, DASH Introduction Fishing continues to be a favorite pastime in the United States. In 2001, 16% of the US population 16 years old and older spent an average of 16 days fishing. 1 A study published by the American Fly Fishing Trade Association 2 reports 18.3 million people aged 16 or older (9% of the adult population) fish but have never fly fished and are interested in fly fishing. It is anecdotal among those who cast fly rods that pain symptoms in the upper extremity are common, occasionally leading to days taken off from fly fishing. Back and joint pains have also been associated with fly fishing. 3 However, no studies quantify these injuries or symptoms in the medical literature. The main objective This work was presented at the Annual Meeting of the American Medical Society for Sports Medicine, San Diego, CA, April 2003. Corresponding author: Timothy J. McCue, MD, 634 Eddy Ave, The University of Montana, Missoula, MT 59812 (e-mail: tim.mccue@ mso.umt.edu). of this project was to identify the prevalence of pain and disability of the upper extremity in professional fly-casting instructors. We hypothesized that overuse injuries of the hand, wrist, elbow, and shoulder occur frequently in professional fly-casting instructors, and that the severity of symptoms depends on the type of equipment used, casting style, and the extent of participation. Methods PARTICIPANTS Participants were randomly selected from 812 individuals living in the United States who have completed the rigorous Federation of Fly Fishers (FFF) Casting Instructor Certification Program. This group of professional fly-casting instructors represents a cross section of people who typically cast fly rods during more than 50% of the year. Fly-casting instructors certified by the FFF

268 McCue, Guse, and Dempsey demonstrate a high proficiency in fly-casting techniques for multiple scenarios including distance, obstacles, and accuracy. Approval for this work was obtained from the Institutional Review Board of the Medical College of Wisconsin. Completion and return of surveys was deemed to indicate consent by participants; therefore, the requirement for written informed consent was waived by the review committee. SURVEY INSTRUMENT A survey instrument was designed to capture fly-casting style, equipment characteristics, and physical pain and disability symptoms of the shoulder, elbow, wrist and hand. The style and equipment portion included primary fly-casting arm, reeling dominant hand; standard casting style (overhead, sidearm, elliptical); types of fish sought (light coldwater, heavy coldwater, light warm water, heavy warm water, light saltwater, heavy saltwater, offshore); caster s single-handed fly-rod equipment specifications (weight, length, rod action, rod handle, gripping style) for up to 3 different rods and the duration and frequency with which each rod was used; and use of any of the following techniques: single hauling with singlehanded rod, double hauling with single-handed rod, routinely casting over 75 feet with a single-handed rod, use of double-handed rods, casting with shooting heads, and using extra weight when fly casting. Questions regarding physical symptoms in the shoulder, elbow, and wrist were patterned after survey questions for joint-specific (elbow, wrist, and shoulder) assessment of function reported by MacDermid et al and by the Research Committee of the American Shoulder and Elbow Surgeons. 4,5 Participants were asked to rate pain frequency (0 never, 7 always) and severity (0 no pain, 7 worst ever) on an 8-point Likert scale and to indicate the duration of their pain and its temporal relationship with casting. The Disability of the Arm, Shoulder, and Hand (DASH) questionnaire 6 was included to obtain an overall physical disability score, as well as the DASH sport and DASH work modules. PROCEDURES A current mailing list was obtained from the FFF. Surveys were mailed to a random sample of 577 individuals. Sample size was determined to be able to estimate proportions within 5% with 95% confidence, assuming a true proportion of 0.50 and a 67% response rate. We hoped to receive at least 385 responses. Participants were asked to return surveys anonymously in prepaid mailing envelopes. A second mailing was sent to nonresponders. ANALYSIS An indicator variable was constructed from the shoulder, elbow, and wrist pain-frequency questions to indicate the presence or absence of pain at any of those 3 sites. A response of 4 to 7 on the Likert scale for pain severity was defined as moderate-to-severe pain. A total disability score between 0 and 100 was calculated for the DASH responses by the standard method, where a higher score reflects greater disability. 6 The following factors were considered as possibly related to the various pain measures: ever fishing for various types of fish; length, weight, and action of rod used the most days of the year; fly-fishing rod days per year (defined as the sum of days for each of up to 4 different rods); single hauling with single-handed rod; double hauling with single-handed rod; routinely casting over 75 feet with a single-handed rod; use of double-handed rods; casting with shooting heads; and using extra weight with sinking flies. An indicator variable for heavy fish was defined as fishing for any heavy coldwater, heavy warm water, heavy saltwater, or offshore fish. Binomial CIs were calculated for pain prevalence percentages. The relationship between casters equipment, casting style, and physical symptoms was evaluated by the Fisher exact test, Wilcoxon rank sum test, or chi-square test, depending on the nature of the data. Sample sizes vary for many of the analyses because of missing data. No particular pattern for missing data could be discerned. Data were analyzed by Stata and StatXact software. 7,8 Results Two hundred ninety-two usable surveys were returned for a response rate of 51%. Three surveys were returned as undeliverable and 2 were returned blank. Respondents fly-casting characteristics are shown in the Table. Most of the participants in this study fly cast right handed, have their reel set up to retrieve fly line left handed, and were overhead fly casters. A total of 49.8% of respondents (95% CI, 43.9% 55.8%) reported shoulder pain, 39.0% (95% CI, 33.3% 44.9%) reported elbow pain, and 36.1% (95% CI, 30.6% 42.0%) reported wrist pain. Seventy-four percent of respondents (95% CI, 69% 79%) reported pain in at least 1 of these locations, though only 25% (95% CI, 20% 30%) recorded pain at 1 of the 3 locations as moderate or severe (4 or greater on the Likert scale). Scores for DASH ranged from 0 (no disability) to 65.5 with a mean of 6.5 (SD 8.9). Four percent (13) of respondents had DASH scores of 25 or greater, indicative of at least mild disability. Only 2% of respondents (5) in-

Upper Extremity Pain in Fly Casters 269 Fly-casting characteristics Characteristic n % Fly cast with right hand* Fly cast with left hand* Reel with right hand* Reel with left hand* Overhead fly cast Sidearm fly cast Elliptical fly cast 269 16 102 181 194 83 19 92.1 5.5 34.9 62.0 66.4 28.4 6.5 *Right-hand plus left-hand percentages do not add to 100% because of missing data. Not mutually exclusive. dicated that they had missed work because of pain, but 27% (79) reported changing their casting style because of pain. Respondents were asked to indicate how long pain lasted by choosing from among hours, days, weeks, months, and all year. Of those reporting shoulder pain, 58% indicated it lasted for hours, 28% indicated that it lasted for days, and 5% indicated that it lasted all year. Of those reporting elbow pain, 33% indicated it lasted for hours, 42% indicated that it lasted for days, 12% indicated that it lasted for weeks, and 4% indicated that it lasted all year. Of those reporting wrist pain, 51% indicated it lasted for hours, 29% indicated it lasted for days, 6% indicated it lasted for weeks, and 4% indicated it lasted all year. The median number of rod days (the sum of the number of days each rod was used) was 100 with a range from 3 to 780. No significant associations were between pain measures and the number of rod days spent fishing per year. FLY-CASTING TECHNIQUE No association was seen between the overhead casting style and the presence of shoulder pain. Sixty percent of those who use multiple fly-casting styles reported shoulder pain, whereas 46% to 53% of those with a single fly-casting style reported shoulder pain, though this was not statistically significant (Figure 1). Chi-square tests revealed significant differences in wrist pain prevalence between the overhead and the sidearm styles (32% vs 49%, P.01), between the overhead and the elliptical styles (32% vs 58%, P.03), between the sidearm and the multiple styles (49% vs 20%, P.05), and between the elliptical and the multiple styles (59% vs 20%, P.03) (Figure 2). Chi-square tests also revealed that only 7% of those using multiple casting styles reported elbow pain, and this was significantly lower than the prevalence in each of the other casting styles (overhead 38%, P.04; sidearm 45%, P.02; elliptical 71%, P.003) (Figure 3). Additionally, the prevalence of elbow pain was significantly lower with the overhead style compared with the elliptical style (P.01, chi-square test). No relationship was seen between the casting style and the DASH score. A majority of those surveyed use both the single-haul and double-haul techniques (72%, 211/292) and an additional 25% used 1 technique or the other. Of the fly casters who used single- or double-haul techniques or both with a single-handed rod, 75% reported some shoulder, elbow, or wrist pain after fly casting, whereas only 33% of those who neither single haul nor double haul reported some shoulder, elbow, or wrist pain (P.04, Fisher exact test). Figure 1. Shoulder pain in relation to casting style.

270 McCue, Guse, and Dempsey Figure 2. (P.05). Wrist pain in relation to casting style. *Statistically significant difference compared with sidearm and elliptical styles Forty-five percent of respondents indicated that they routinely cast over 75 feet with a single-handed rod. Seventy-nine percent of these fly casters reported some shoulder, elbow, or wrist pain, but this was not significantly different from the 69% reporting pain in the group that does not routinely cast over 75 feet. TYPES OF FISH SOUGHT Thirty-one percent of those who fish for heavy saltwater fish reported moderate-to-severe shoulder, elbow, or wrist pain after casting compared with 19% of those who have not fished for heavy saltwater fish (P.03, chisquare test). This significant difference persisted in a multivariate logistic regression, which controlled for casting style and pain caused by other activities (odds ratio [OR] 2.0, P.02). No significant difference was in the DASH score between those fishing for heavy saltwater fish and those who were not. The prevalence of shoulder, elbow, or wrist pain did not differ significantly for any other category of fish or for the heavyfish indicator variable. Figure 3. Elbow pain in relation to casting style. *Statistically significant difference compared with all other styles (P.05). **Statistically significant difference compared with elliptical style (P.01).

Upper Extremity Pain in Fly Casters 271 SHOOTING HEADS AND WEIGHT Nearly 62% of those surveyed routinely use shooting heads while casting. Seventy-nine percent of those who cast with shooting heads reported shoulder, elbow, or wrist pain after casting compared with 66% of those who do not (P.04, chi-square test). The majority of those surveyed (79%) added weight to sinking flies when fly casting. Seventy-eight percent of those who use extra weight with a nymph, streamer, or other sinking fly reported shoulder, elbow, or wrist pain after casting compared with 60% of those who do not (P.01, chisquare test). GRIP STYLE Over 85% of respondents reported using the thumb-ontop grip style with their most used rod. In examining grip style of the most used rod and pain and symptom measures, a significant relationship was found between frequency of shoulder pain and grip style (P.04, exact Kruskal-Wallis test with Monte Carlo sampling). However, this appears to be because everyone reporting the V-style indicated that shoulder pain was less than 3 on the Likert scale. Among those using the other grip styles, 13% of the finger-on-top, 19% of the 3-point, and 7% of the thumb-on-top users reported shoulder pain with a severity of 4 or greater. Eighty-eight percent of those responding to both the grip style and the shoulder pain questions reported using the thumb-on-top grip style. Fly rod characteristics The weight class of the most used fly rod ranged from 2 to 15 with a median of 5. Weight class of the fly rod was significantly and positively correlated with degree of wrist pain (Spearman rank correlation 0.13, P.03). Rod length varied from 4 to 15 feet with a median and mode of 9. Each additional foot of length increased the odds of reporting some pain in the shoulder, elbow, or wrist by 46% (OR 1.46, P.03). No significant associations were seen between the various pain measures and the rod action. Discussion This is the first study investigating the association between specific techniques and methods of fly casting and the prevalence of self-reported pain. In this group of respondents, 74% reported some pain in the shoulder, elbow, or wrist, though only 25% reported moderate-tosevere pain. FLY-CASTING TECHNIQUE The fly cast has 2 motions: the forward motion of the cast moves from posterior to anterior casting the line forward, whereas the backward or the back cast motion of the cast moves from anterior to posterior sending the line behind the caster. There are 3 primary fly-casting styles. Each style uses a specific angle of the fly rod with both motions of the cast. The overhead style has a forward cast and a back cast at an angle near 90 to the sagittal plane. The sidearm casting style has a forward cast and a back cast at a45 angle to the sagittal plane. The elliptical style is a combination of both overhead and sidearm styles with a back cast at a 45 and forward cast in the near 90 angle position. The overhead style, which is the most common flycasting style, is associated with less elbow and wrist pain than either the sidearm or elliptical styles. People who use multiple fly-casting styles have less elbow and wrist pain than do those who primarily use 1 method. Using multiple fly-casting techniques results in varying degrees of power from the musculature and ligaments that attach to and cross the elbow, perhaps limiting overuse injuries at a particular area of the elbow. We found that those who use a haul in their fly cast have more pain symptoms than those who do not, which is likely related to increased torque on the arm with the haul. Loading the fly rod is a reference to the flexing of the fly rod against the weight of the line during the casting stroke. 9 Loading during the cast increases the stored energy in the fly cast, which then transfers this energy into the speed of the fly line being cast. A haul is a method of loading the rod that increases line speed and casting distance by pulling the fly line with the noncasting hand in the middle of the fly-casting stroke. The fly caster can pull on the line once only during the back cast (the single haul) or twice with both the back cast and the forward cast (the double haul). Surprisingly, we found no significant association between routinely casting over 75 feet and pain symptom scores. This may be because of our data collection method (ie, using selfreported casting distance) or because it is actually the haul, and not casting distance, that increases risk of upper extremity pain. TYPES OF FISH SOUGHT Those who fish for heavy saltwater fish have a higher prevalence of severe pain after casting. This may be because fishing for heavy saltwater fish requires the most strength and power in the fly-cast of all the fish species subsets. Tarpon, ranging from 40 to 100 pounds, is a

272 McCue, Guse, and Dempsey species included in the heavy saltwater fish category. Fly casting for tarpon typically involves periodic long casts with heavy flies and heavy equipment. SHOOTING HEADS AND WEIGHT Weight is often added to fish the fly at a certain depth in the water. A caster can add weight to the fly line by directly adding pieces of weight to the end of the fly line or by using a fly tied with extra weight (sinking fly). Another option for adding weight to the fly line includes using a weighted shooting head at the end of the fly line. A shooting head is a short length of heavier fly line designed with a weighted core. It is manufactured in various lengths and weights and can be used in the cast to further load the fly rod, thereby producing more distance. Any of these methods of adding weight increases the mechanical stress to the arm during the fly cast and is associated with pain symptoms. GRIP STYLE Fly-casting grip styles include the thumb-on-top, 3- point, V-style, and finger-on-top and vary in placement of the thumb and index finger, resulting in different hand rotation and position during the cast. For example, the 3-point and finger-on-top grips keep the hand in full pronation throughout the cast, the thumb-on-top grip keeps the hand in the neutral position, and the V-style grip is in between. Rotation in the wrist can cause different forces on the wrist and elbow throughout the cast; however, we found no convincing relationships between wrist or elbow pain and grip style of the most frequently used rod. Moderate-to-severe shoulder pain was seen more often in the 3-point and the finger-on-top gripping styles. LIMITATIONS OF STUDY This study has several limitations. The survey instrument used did not allow us to determine whether pain reported was due in full or in part to fly casting rather than some other activity of the respondent. Fifty-eight percent of respondents reporting some shoulder, elbow, or wrist pain indicated that there were activities other than casting that caused pain in their upper extremities. Also, 5 of the 13 respondents with DASH scores of 25 or greater attributed their pain to a cause other than fly fishing. This study was designed to investigate the association between fly-casting characteristics and pain symptoms, but causality was not addressed and additional research is needed in this area. Another limitation of this study is that the findings may not be generalizable to all fly casters because of the study population selected. This group was chosen because of the frequency with which they fly cast and the availability of a mailing list. Because these individuals are professional fly-casting instructors, they are a population who fly casts routinely (often greater than 50% of the year) and with outstanding technique. The FFF Casting Instructor Certification Program was begun in 1992 for the purpose of enhancing the overall level of instruction in fly casting. Fly-casting certification is a rigorous series of tests, as the participants must be able to demonstrate impeccable fly-casting technique for multiple scenarios including distance, obstacles, and accuracy. If proper casting technique reduces the occurrence of pain symptoms caused by fly casting, then this study may underestimate the prevalence of pain symptoms in less skilled fly casters. It is possible that there could be more injuries and overuse syndromes in those who fly cast less frequently because of poorer technique and more deconditioned fly-casting musculature. Conversely, our sample may report a higher prevalence of pain symptoms caused by more frequent fly casting and higher risk of overuse syndromes. Our measure of rod days is an underestimate because of missing data. Thirty-three respondents listed 74 rods (8% of all rods described) for which they provided no information on days used per year. Additionally, this study group was largely men; findings may differ among women. Last, many statistical tests were conducted, increasing the chance of making a type I error. Therefore, our results should be interpreted with some caution but can provide direction for future research. CONCLUSIONS AND CLINICAL APPLICATION Pains in the shoulder (50%), elbow (39%), and wrist (36%) are prevalent in this group of high-level fly-casting instructors, though moderate-to-severe pain was reported by only about 25% of all respondents. Our results suggest that an overhead fly-casting technique should be instructed initially to avoid upper extremity pain symptoms in the beginning fly caster. Many variations of the fly cast can be added with time to the angler s repertoire for different scenarios encountered in fly casting. The results of this study may be useful in recommending fly-casting techniques to alleviate pain symptoms in specific upper extremity areas. As people continue to learn to fly cast and improve their own flycasting skill, the results of this study may help prevent upper extremity symptoms on the river. Although FFF casting instructors are versed in all flycasting techniques, in teaching others, instructors are

Upper Extremity Pain in Fly Casters likely to emphasize the technique they use most often themselves. Knowledge of the relationship between flycasting style, fly-fishing equipment, fish species pursued, and upper extremity pain may reduce symptoms and days lost from fly casting. Proper instruction will give beginners a smoother entry into fly fishing and will give experienced fly fishers an opportunity to build on existing fly-casting skill. Fly-casting symptoms seen in the physician s office should not be treated as typical overhead throwing injuries such as those seen in pitchers and tennis players. It is important to remember that the fly-casting stroke varies from the standard phases of overhand pitching motion, as there is no windup or follow-through in fly casting. Fly casting incorporates the posterior musculature of the shoulder as well, with the back cast reversing the throw. In theory, there is equal torque and force with both the back cast and the forward cast, leading to symptoms on both planes of the shoulder, elbow, and wrist. Because of the differences between the fly-casting stroke and the overhand pitching motions, preventative and rehabilitative exercise programs should focus on both anterior and posterior structures of the shoulder and shoulder girdle. This analysis investigated pain symptoms seen with specific techniques of fly casting in an elite group of fly casters. Important areas for future research include evaluation of pain symptoms in other populations, such as women and nonprofessional fly casters, and the association between pain symptoms and temporary or permanent discontinuation of fly casting and other activities. Acknowledgments The authors thank Jason Borger for assistance with the fly casting inventory; the Federation of Fly Fishers for 273 assistance with the mailing list; Mary Kelly for assistance with the distribution and administration of survey forms; and Linda Douglas, MD, and Bruce Ambuel, PhD, for assistance with project planning. This work was supported by the Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI. References 1. US Fish & Wildlife Service. 2001 National Survey of Fishing, Hunting, and Wildlife-Associated Recreation. Available at: http://www.census.gov/prod/2002pubs/ FHW01.pdf. Accessed August 31, 2004. 2. American Fly Fishing Trade Association. Fly Fishing in the United States [consumer demographic study]. Available at: http://www.affta.com/consumer demo study.htm. Accessed August 31, 2004. 3. Berend KR. Prevalence of orthopaedic maladies in people who flyfish: an Internet-based survey. J South Orthop Assoc. 2001;10:221 229. 4. Research Committee of the American Shoulder and Elbow Surgeons. A standardized method for assessment of elbow function. J Shoulder Elbow Surg. 1999;8:351 354. 5. MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma. 1998;12: 577 586. 6. Solway S, Beaton DE, McConnell S, et al. The Dash Outcome Measure User s Manual. 1st ed. Toronto: Institute for Work and Health; 1997. 7. Stata Statistical Software [computer program]. Release 7.0. College Station, TX: Stata Corp; 2001. 8. StatXact-Turbo [computer program]. StatXact software version 2.11. Cambridge, MA: Cytel Software Corp; 1992. 9. Borger J. Jason Borger s Nature of Fly Casting. Wausau, WI: Shadow Caster Press; 2001.