Upper Extremity Golf Injuries (End)

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Elbow

Traumatic injuries are often the result of striking an object other than the golf ball. Professionals and amateurs can sustain elbow injuries when hitting the ball out of long, thick grass called heavy rough. When the clubhead sweeps through heavy rough, the hosel (the junction of the shaft and clubhead) can become entangled in the long grass creating a large deceleration of the clubhead through impact resulting in high strain across the forearm flexors. Similar deceleration injuries occur with hitting the ball “fat” or striking a tree root or rock.

Overuse injuries can be a consequence of repetitively gripping the club too tightly, which is a common fault in amateur golfers. Gripping too tightly strains the forearm musculature sometimes leading to injury. Elbow injuries are quite common in amateur and female golfers. Two of the most common elbow problems in golfers are lateral and medial epicondylitis.

Lateral Epicondylitis

Lateral epicondylitis most commonly involves the lead arm. It is usually an overuse injury due to repetitive, vigorous contraction of the extensor carpi radialis brevis as with gripping the club too tightly. The lead elbow experiences high stresses across the extensors. The extensor muscles are very active at impact to help stabilize the left wrist. Hitting the ground firmly at impact places added stress across the extensors. Amateurs have been shown to experience lateral epicondylitis, or “tennis elbow,” five times more frequently than medial epicondylitis “golfer’s elbow.” Signs include tenderness to palpation over the ECRB origin and pain with resisted wrist extension. There is often pain associated with gripping objects tightly or shaking hands.

Non-operative treatment of tennis elbow typically involves a combination of modalities. The patient should limit their golfing and orther aggravating activities acutely along with a short course of non-steroidal antiinflammantory drugs to help with the pain. After the acute pain improves, a course of rehabilitation can begin consisting of stretching, strengthening, and modalities. Steroid injections are also an option option. One study showed that steroids can alleviate pain but ortherwise provided no benefit.  Wrist splints can also play a role in treatment. There was a recently published randomized, prospective study of forearm straps versus extension wrist splints for the treatment of lateral epicondylitis. Along with bracing, patients were allowed icing and home stretching exercises. Functional outcomes were no different, but wrist extension splints provided greater pain relief at 6 weeks.

Surgery should be considered if 6 to 12 months of non-operative treatment fails. Either open or arthroscopic techniques can be used with a high rate of successful outcomes. Proponents of arthroscopic treatment cite the added benefits of treating associated intra-articular pathology (40% to 63%), such as synovitis or loose bodies, and earlier return-to-work (6 to 8 weeks earlier). Ultimately, the surgeon should utilize the technique with which he or she feels most comfortable. On pathology, the diseased tissue is typically found within the extensor carpi radialis brevis origin. It consists of disorganized collagen, immature fibroblasts, and vascular elements termed angiofibroblastic tendinosis.

Medial Epicondylitis

Medial epicondylitis is the second most common source of elbow complaints in golfers. It typically involves the trailing arm in golfers. Medial elbow injuries result from sudden deceleration of the clubhead, while lateral elbow injuries are attributed more commonly to overuse. Therefore, most medial elbow injuries in the golfer are of a traumatic nature occurring at impact. However, the common amateur swing fault of “casting,” or extending the wrists at the initiation of the downswing, overloads the right forearm flexors and can be contributing factor to medial epicondylitis. At ball impact, the flexor muscles have an activity burst to 90% capacity to stabilize the right wrist. Striking the ground at impact adds to the stress at the medial elbow.

Medial Epicondylitis
A, A golf club that is too short will leave the end of the club lying against the hypothenar eminence. B, This puts the hook of the hamate at risk of fracture at impact.

Non-operative treatment of medial epicondylitis is similar to the treatment of lateral epicondylitis. It typically involves a combination of modalities: rest, non-steroidal anti-imflammatories, physical therapy, bracing, and corticosteroid injections.

Operative treatment may be considered after at least 6 months of unsuccessful non-operative management. Surgery consists of an open debridement of pathologic tissue from the common flexor origin, repair of the defect, and reattachment of the flexor origin. The location of the diseased tissue is less consistent with medial epicondylitis but often is found the interval between flexor carpi radialis and pronator teres. Symptoms of ulnar nerve compression may be encountered in up to 24% of patients treated operatively for medial epicondylitis. Consideration should be given to ulnar nerve decompression and possible transposition in these cases.

Elbow Injury Prevention

The incidence of elbow injuries increases with frequency of play between the ages of 35 and 55. Mistakes in the backswing can lead to compensatory motions on the downswing to bring the clubhead back on plane. Both laying the club off at the top of the backswing or too steep of a backswing require compensatory use of the hands and wrists to get the clubhead back on track for ball impact. Theses swing faults performed over a long period of time may lead to overuse injuries at the elbow. Extending the wrists at the initiation of downswing not only leads to unpredictable shots but also stresses the forearm flexors and extensors. Additionally, oversized grips may help to decrease the forces across the forearm flexors and extensors to decrease the incidence of medial and lateral epicondylitis.

Wrist and Hand

The wrist is a very common site of golfing injuries. The wrist accounts for up to 20% of amateur golf injuries and 20% to 27% of injuries in professional golfers. In order to execute a proper swing, both wrists must move through an extensive range of motio. Most wrist injuries occur at impact from sudden deceleration and are traumatic in nature. Amateurs often sustain these injuries from hitting “fat” shots or striking the ground with the clubhead prior to making contact with the ball. Professionals tend to get these injuries from striking a tree root, rock, or hitting out of thick, heavy rough. Depending on the force transmission, an acute injury may occur or if done repeatedly a pattern of overuse injury may develop. Flexor carpi ulnaris tendonitis, extensor carpi ulnaris dislocation, and hook of the hamate fractures all occur through this mechanism.

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