Golf Injuries: A Review Of The Literature (P3)
Specific Injury Sites
Low Back Injuries
The low back has been reported as being the most common site of injury in a golfer, accounting for 23.7–34.5% of all injuries. Due to the mechanicsof the swing, the low back is subject to large ranges of motions and forces. The forces that occur as a result of the mechanics of the golf swing may be categorised as:
- downward compression
- side to side bending
- sliding, back to front shearing.
Peak compressive load during the golf swing has been shown to be 8-times bodyweight (compared with rowing [7-times] or jogging [3-times]).
In an analysis of the differences in the golf swing of amateurs and professionals, research has found that amateurs reach 90% peak muscle activity compared with 80% in professionals and the lumbar spine is under more load in amateurs. The study found that both groups of players had the same compression loads, but amateurs incurred 80% more lateral bending and peak shear loads and 50% more torque than their professional counterparts. Anecdotal evidence from personal observations/experiences of the authors suggests that these characteristics are mainly due to the amateur player trying to hit the ball further by swinging harder, particularly with the driver (the club used to hit the ball the furthest distance). The professional player has practised enough to produce a nearly identical swing each time they play a full shot. As a result of this practise, their swing is grooved and becomes second nature and thus efficient to them. In most cases, amateurs lack this desirable feature and this may predispose to injury as poor swing mechanics increase the forces generated by the golf swing.
The golf swing is a complicated action with intrinsic and extrinsic factors affecting the golfer’s ability to hit the ball with power and accuracy. As a result of this complexity, injuries can occur. If the swing is not as free flowing and as efficient as possible, injuries are likely to occur.
The golf swing involves a large range of motion and is repetitive, especially during practise. Combined with the large forces produced in the lower back, this may result in the increased risk of strains, disc herniation and facet arthropathy.
A number of swing types are common in golf. A basic understanding of the golf swing types is required for practitioners to be able to understand how golf swing-related injuries may occur. There is the classic golf swing that was popular in the early/mid part of the twentieth century and there is the modern swing that Jack Nicklaus introduced in the 1960s. The modern swing generated more power to the ball, increasing the distance the ball travelled. It also produced higher shots that stopped shortly after landing, which was helpful in shots to the green. The main differences in the swings was the large pelvic and shoulder rotation in the classic backswing as opposed to the limited pelvic rotation compared with shoulder rotation in the modern backswing (figure 1). This differential in rotation generates a coiling effect of the trunk that helps with power development. The follow-through position was also different with a relatively neutral spinal position and forwards body momentum in the classic swing as opposed to the hyperextended spine and upwards body momentum on the modern swing (figure 2). This reverse ‘c’ position of the follow-through in the modern swing (producing hyperextension of the lumbar spine and right lateral flexion) has the poten tial to result in facet irritation if constantly repeated. A third swing is gaining popularity, which combines elements of both swing types. The hybrid swing utilises the backswing of the modern swing with its power generating potential and the follow through of the classic swing with its neutral spine. This swing is thought to generate similar power to the modern swing, without the hyperextended spine (and potential for injury) of the modern swing.
Refuting the data that show that golf may increase the likelihood of experiencing discal problems is research that showed golfers had 0.59 relative risk of herniated disc to those that do not play sport, while those that play >2 times per week have 0.19 relative risk. This raises the question of whether golf has a protective mechanism to discal problems compared with not playing the game. However, golfers with discal-associated low back pain would not play golf due to the belief that the golf swing will aggravate their condition. Thus, there may be some selection bias in this finding.
Sugaya et al. examined the prevalence of low back pain amongst elite/professional golfers at three major golf tournaments and final qualifying test. Of the 283 golfers that responded (only one player was left handed and excluded from the study for consistency purposes), the most common injury site was low back, followed by neck/high back and elbow and shoulder equally. Of these golfers, 72% experienced injuries that caused them to miss a tournament or perform at a lower level. An injury to the low back was responsible for missed play 55% of the time. Of the players who experienced low back pain and recorded pain location, 51% had right-side pain, 28% left side and 21% central. An important statistical correlation between right-sided back pain and the follow-through was found when analysing where the pain occurred during the swing (p < 0.05). This study also took radiographs of 16 players (there was no selection criteria, which raises the question of selection bias) with low back pain and found that compared with age-matched controls, golfers had statistically more osteophytic formation at L3/4 (p <0.01), and in total (p < 0.01). They also found that facet changes were statistically different overall (p < 0.01) and at L4/5 (p < 0.01) and L3/4 (p < 0.05).
In another study, Burdorf et al. conducted a 1-year prospective study on back pain amongst males taking up golf. 221 completed the first survey (88% response) with 89% completing the follow-up survey (196). The baseline survey showed the life-long cumulative incidence of back pain as 63%, with a 28% reporting a history of back pain within the 1 month prior to the completion of the survey. Those that were athletes had an odds ratio of 2.1 for previous back pain compared with non-athletes. During the 12-month prospective period of the study, 8% reported a first time occurrence of back pain and 45% reported the recurrence of back pain. Only six subjects attributed golf to this recurrence. Compared with those who only played golf, those who also played one other sport had a risk of 1.4 to recurrence of back pain.
The rate of back injury in junior golfers has been investigated. This study found that the incidence of back pain in golfers was not different to agematched controls when compared with others studies in similar aged children. However, in those junior golfers with back pain, most pain was reported to occur in the right lumbar region. This figure correlated to right side lumbar pain in 93% of right handed players. This right side predominant pain location in right-handed golfers is similar to that found in professional (adult) golfers described by Sugaya et al.
Compression fractures in older females during the golf swing have been reported in the literature. The compression fracture sites were confined to the lower thoracic and upper lumbar vertebrae, and were reported in healthy postmenopausal women who were previously diagnosed, or subsequently diagnosed, with osteoporosis. This shows that the most common site of stress in the back appears to occur around the thoracolumbar region, a transition segment of the spinal column. The question that needs to be asked is “If there was no osteoporosis, would the compression fractures have occurred?”. Further research into this area is needed.
Along with the low back, the wrist is the most common site of injury in golfers. The wrist provides the anchor point of the club to the arms and body during the swing. As such, the wrist moves through a relative wide range of motion during the swing. Motions include flexion, extension, radial and ulnar deviation, with pronation and supination of the forearms also being a feature of the golf swing.
The most common injury mechanism in wrist injuries occurs as a result of hitting an object other than the ball. These injuries are usually of the acute nature. The injury is the result of a sudden decrease in movement of the accelerating hands and wrist at impact that can produce enough forces to disrupt tissue structures. Injuries of this nature tend to occur at the hand and wrist, but can also occur in the elbow. Muscular strains and ligamentous strains are common, but fractures of the hook of hamate may also occur due to this mechanism. Hitting off stones of hard ground may also produce similar injuries. The hitting of a ‘fat’ shot, i.e. hitting the ground first during the process of hitting the ball is another possible source of this mechanism of injury, which tends to occur mainly in the amateur ranks. The professional golfer can sustain a similar type of injury in slightly different circumstances. In major tournaments, particularly at the links courses of the UK, the rough tends to be quite thick and long. As a result, if a ball is nestled in the rough, a lot of force is required just to get the ball back onto the fairway. Combine this with the fact that long strands of grass tend to wrap themselves around the hosel and shaft of the club during the downswing, which has the potential to place more force on the upper limb and cause injury.
Other injury mechanisms that involve the wrist are overuse related, often due to the repetitive nature of practise, or from changes to the swing that result in stress to structures unaccustomed to the type of stress the golf swing produces. A study of the Spain National Insurance Scheme for sportspeople found that 10% of golfers experienced a wrist injury. Causes of wrist injury were reported as overuse or sudden change in swing. This survey found that wrist injuries from golf may be categorised as either articular (mostly occurring via fractures, particularly the hook of hamate) or extra-articular most often tenosynovitis, with the flexor carpi ulnaris the most common site of injury.
Hook of hamate fractures result from the hamate becoming impinged between the hand and the butt end of the club. This results in a fracture of the hamate of the leading hand, for example the left hamate in a right-handed golfer, and has been reported in the golf injury literature as far back as 1972. Stress fractures may also occur at this site due to sudden increases or changing the golf club grip.
The site of pain with a hamate fracture is in the hypothenar area of the palm, with tenderness to palpation of the hamate an indication for imaging. However, plain x-ray films may not initially show the fracture. A carpal view x-ray may show the fracture, although a CT of the wrist should show the injury if there this film is negative and there is still a clinical suspicion for it.
Complications to the healing of the fracture in clude non-union of the fracture site, a concomitant ulnar nerve lesion and/or the rupture of the flexor tendons over the broken edge of the hamate. Hook of hamate fractures tend to present late (usually several months after the injury) and often require surgical excision of the fracture segment at this point.
Tendinitis is a much maligned term used to describe overuse syndrome about the wrist/elbow, with the term tendinopathy been indicated for use as a general clinical descriptor. It has an overuse mechanism, which results from either a sudden increase in the volume of practise or the changing of the grip (causing increased loading on an unaccustomed part of the wrist), and subsequent practise. It is gradual in onset, persistent in nature and continues until the aggravating factor(s) is stopped or rested until allowed to heal.
Large forces are produced in the golf swing just prior to impact, particularly in the flexor tendons. In the case of right-handed golfers, the flexor carpi ulnaris of the right wrist is vulnerable to injury from microtrauma due to these forces, particularly when golfers take divots (hit the ground). There is a slight increase in resistance experienced as the club encounters the ground, a resistance that heavily loads the flexor tendon. In addition, beginner golfers may experience pain due to extensor carpi ulnaris overuse, which is the result of ‘casting’ the golf club early in the downswing (the early uncocking of the wrist during the downswing and a source of lost power and control).
Unusual cases of injury in the surrounding structures also occur. Hsu et al. reported the case of an amateur golfer with mechanical compression of the median nerve in the right palm by the head of the first metacarpal bone of the left hand. This compres sion may occur during the acceleration phase of the downswing just prior to impact, particularly if the right hand is leading the left hand during the downswing and if the right-hand grip is too tight.
Abnormal anatomy along with overuse can also produce injury of the wrist. Oka and Handa reported the case of a 20-year-old golf trainee present ing with right wrist pain when swinging the golf club during a practise session. Examination revealed extensor carpi ulnaris tendon dislocation past the ulnar head and to the ulnar-volar side on supination of the forearm. On returning to the neutral position, the tendon reduced in a snapping manner, extending beyond the ulnar head, which reproduced the pain. Surgery to partially resect the ulnar dorsal ridge of the ulnar head with release of the extensor rectinaculum resulted in resolution of symptoms.
A highly unusual case of hypothenar hammer syndrome in a golfer has been reported. Hypothenar hammer syndrome results from a thrombus formation of the ulnar artery with hand ischaemia. They usually occur in occupations that involve vibrating tools and those people who hammer objects with their hypothenar eminence, hence its name. Most cases that occur in the sporting arena occur in baseball and are the result of repetitive blunt trauma. In the presenting case, the proposed mechanism was the repetitive hitting of practise balls with a ‘faulty’ grip causing repeated pressure on the ulnar artery underlying the hypothenar eminence, which resulted in injury and thrombus formation.
McHardy and Pollard have reported of the unusual onset of wrist pain after a change in the putting grip, which resulted in the supination of the right wrist in a right-handed golfer. This grip change caused increased stress on the insertion of flexor carpi radialis and resultant pain. Manual therapy and a return to the previous grip resolved symptoms.