Golf Injuries: A Review Of The Literature (P4)
Specific Injury Sites
The elbow is a common site for injury, particularly in amateur and female golfers. A possible reason suggested for this is the increased carrying angle found in females. Although injury to the common flexor bundle at the medial epicondyle is commonly called ‘golfers’ elbow, it is the lateral epicondyle that is the site of more golf-related injuries. In a study of golf injuries, McCarroll et al. found that of all elbow injuries, 85% occurred to the lateral aspect. Differences in the mechanism of injury are the likely explanation for this difference. A sudden deceleration of the club head can result in injury to the medial aspect of the elbow, while overuse is the more likely mechanism to occur at the lateral aspect of the elbow. Traumatic injury usually occurs as the result of hitting an object at impact (other than the ball) during the swing. In professionals, this is mostly the result of hitting an obscured tree root/ rock in the rough or trying to hit the ball out of heavy rough (for example St Andrews at the British Open). This may also occur in amateurs. In addition, a more common mechanism involves the amateur hitting the ground first when attempting to hit the ball (hitting a ball ‘fat’). A possible explanation for hitting the ball ‘fat’ is poor swing mechanics and with a steep downswing predisposing to hitting the ball ‘fat’.
Besides the traumatic injuries, overuse injuries often result from changes in the grip of amateurs. Gripping the club too tight and having golf club grips that are slippery are also common causes. All of these factors result in changes in forces generated in the forearm musculature and are a source of potential injury.
In the golf downswing, just prior to impact, there is a large increase in wrist flexor activity, the flexor burst. At this point in time the right wrist is still radially deviated and extended, but moving towards neutral. This combination places a large amount of stress on the wrist and may result in an acute injury if the ground is hit or a gradual injury from excessive practise due to microscopic damage. Some of these forces can be transmitted to the elbow and result in injury to the medial elbow in the right arm (trail elbow) in the right-handed golfer or to the lateral elbow in the left arm (leading) in right-handed golfers.
To combat these overuse injuries, research has been conducted on the use of braces and larger sized golf grips on the forces generated in the forearm muscles. Interestingly, there was no statistical difference in forces produced between those that used the devices compared with those that did not use them. Even though the elbow is a common injury site in golfers, little research has been conducted in this area. Most of the elbow injury mechanisms and management plans are based on racquet sports-related injuries.
Although knee injuries are not a leading cause of golf injuries (approximately 6%), the forces produced in the knee can be large. The right knee has its peak force at the end of the backswing when the club is moving slowly (compression 540N). The left knee has its peak force near impact and follow-through (compression 756N). Add to these compressive forces, the fact many of the golfers are older and experience osteoarthritis in the hips and knees (with reduced range of motion), the issue of the effect of golf on arthritic knees needs to be evaluated. Also as many in the golfing population may have undergone total hip or knee replacements, the question of the replacement on golfing activity is of much interest.
Mallon and Callaghan conducted surveys of both golfers who had a total knee replacement and also knee surgeons. They found that most (87%) had no pain during play and only 35% reported mild pain after play. However, pain in the left knee during play and pain after play was statistically different (p <0.01) to pain in the right knee. Most surgeons (94%) did not discourage golf and 90% reported not giving any particular instruction to patients, while the remainder told patients to start with short shots and also use a shorter, easier swing after the procedure. Seventy-two percent of surgeons thought golf would not affect those with a knee replacement, while two-thirds recommended the use of a cart whilst playing. The average age of the respondents was 65.4 years who played golf 3.7 times per week. Handicap increased by 1.9 strokes compared with their handicap at the time of the operation, while they lost 11m (12.2 yards) off their drives. However, the average follow-up period from the operation was 4.7 years. Whilst these figures appear to suggest falling performance following total knee arthroplasty, the fact that the operation was, on average, 4.7 years earlier and the subjects were 4.7 years older must be considered a confounding variable in measures of range of motion, power, etc. Much of the fall could be explained by aging as opposed to any consequences associated with the procedure.
Although extremely uncommon, fractures of the patellar due to golf have been reported in the literature A case study reported a golfer who experienced a patellar osteochondral fracture during the follow-through of a drive. Internal rotation of the femur on the tibia was the proposed mechanism of injury. The patellar slides tangentially over the lateral femoral condyle with the knee in the flexed position, which may result in an oesteochondral fracture of the patellar or femoral condyle.
A second case study reports a fracture of the patella following reconstruction of the anterior cruciate ligament (ACL). Six months after an ACL reconstruction, the patient was told that he could increase activity. He started to hit golf balls. The patient initially tried short irons, which were okay. He then attempted to use the driver. On the first attempt, he felt a pop with immediate pain and swelling. X-ray revealed a transverse fracture of the patella.
Shoulder pain in golfers is a relatively common occurrence, accounting for approximately 8–12% of all golf injuries, although Gosheger placed this figure at 17.6%. That playing golf causes susceptibility to shoulder injuries is unusual as the sport is not an overhead sport that requires elevation of the humerus. When the humerus is in the overhead position (>90° elevation), the shoulder is susceptible to instability. Most sports with high injury rates for the shoulder complex fall into this category, for example swimming, pitching and racquet sports. However, overuse of the shoulder in the form of excessive practise can produce problems of the shoulder, including but not limited to: subacromial impingement, rotator cuff pathology, acromi oclavicular dysfunction, glenohumeral instability and arthritis.
The shoulder goes through a large range of motion including a large degree of left shoulder horizontal adduction and right shoulder external rotation in the backswing. In the follow-through there is a large degree of left shoulder external rotation and horizontal abduction and right shoulder horizontal adduction. A study on professional golfers (<3 handicap, age range 26–63 years) with shoulder pain found that out of 35 subjects (all right handed), all but one had left shoulder pain, 53% (n = 18) reported pain in the acromioclavicular (A/C) joint and 41% (n = 14) had some A/C osteoarthritis, while 9% (n = 3) had distal osteolysis of the clavicle (this implies a compressional loading to the A/C joint in the horizontal plane).  Hovis et al. found that in elite golfers, those with shoulder pain in the left shoulder (lead shoulder in right-handed golfers) had posterior instability (eight out of a cohort of eight) and many had signs of impingement subacromially (n = 6). They found that the pain and feeling of instability was reproduced at the top of the backswing (maximal horizontal adduction).
In a previous study, Bell et al. found that the position that produced the maximum force across the A/C joint was horizontal abduction and adduction. These positions are similar to those attained by the arm at the top of the back swing (left arm horizontal adduction) and at the end of the follow through (left arm horizontal abduction). This position is also similar to the anterior instability apprehension test (the end position). Therefore, A/C joint injury in high level golfers may be associated with anterior glenohumeral instability and repetitive loading of the A/C joint from hitting a large number of golf balls per day.
When a patient presents with shoulder pain due to the golf swing, the practitioner should ascertain at what point in the swing produces the patient’s pain. Tightness of the posterior capsule, posterior capsulitis or tightness of the rotator cuff musculature often causes posterior shoulder pain at the top of the backswing. If, however, posterior shoulder pain occurs at the end of the follow-through, impingement of either the posterior labrum or the underside of the rotator cuff muscles may be the source of the patients’ pain symptoms. Anterior shoulder pain at the top of the back swing can be caused by impingement of the humeral head and anterior labrum, producing anterior joint line pain, or the pain may be localised to the AC joint indicating possible degeneration or impingement of the AC joint.
Jensen and Rockwood retrospectively reviewed 24 golfers who had shoulder arthroplasty and found that 23 were able to return to play, the other golfer was unable to return to golf due to osteoarthritis of the hip and knee. The 23 that returned to golf had in total 26 shoulder arthroplasties 12 to the left and 14 to the right. All were right handed golfers. Before surgery, 11 patients were unable to play golf, but were able to do so after the surgery. Only three patients reported mild pain during play and six reported mild pain that resolved quickly after play. In the same study, surgeons were asked to complete a survey on patients playing golf after surgery. Forty-four responded and 91% encouraged a return to play. Although this study found that arthroplasty results in golfers being able to return to golf, and useful in its findings it raises more questions than it answers. These questions include:
- Was golf the reason for the shoulder complaint?
- What was the previous sporting history of the patients and how long have they been playing golf?
- Of the 11 patients that were unable to play golf prior to surgery, how many had left shoulder pain and how many had right shoulder pain?
It is known that previous studies have shown that the left shoulder is more likely to be injured by golfers due to larger movements and stress positions, even though the game of golf is less likely to injure the shoulder compared with overhead sports such as swimming, baseball and cricket. The study could make no conclusion as to the aetiology of the shoulder complaints. A prospective long-term investigation is required to provide answers to such questions.