Golf Injuries and Rehabilitation

Transcription

1 Phys Med Rehabil Clin N Am 17 (2006) Golf Injuries and Rehabilitation John R. Parziale, MD a,b, *, William J. Mallon, MD c,d a Department of Orthopedics, Brown University Medical School, 593 Eddy Street, Providence, RI 02903, USA b University Rehabilitation, 450 Veterans Memorial Parkway, East Providence, RI 02914, USA c Department of Orthopedics, Duke University Medical School, Durham, NC 27710, USA d Triangle Orthopedic Associates, 120 William Penn Plaza, Durham, NC 27704, USA There are more than 26 million golfers in the United States, including approximately 6 million avid golfers who play 25 or more rounds of golf per year [1]. An estimated 25% of golfers in the United States are 65 years of age or older. As the population ages, golf is likely to become an increasingly popular leisure time activity because it allows a variety of individuals, regardless of skill, gender, or age, to play simultaneously [2]. As the number of participants increases, the number of golf-related injuries may also be expected to rise. More than 36,400 persons presented to an emergency room in the United States for treatment of a golf-related injury in 1996 [3]. An Australian study of 300 persons presenting to emergency rooms with golf-related injuries reported that 37% were struck by a club, 28% were struck by a ball, 10% had sprains or strains, and 7% had slipped or fallen; 15% of these emergency room visits led to hospitalization [4]. A British survey of 163 amateur golfers reported that 57% had sustained golf-related injuries in a single year [5]. In the United States, amateur golf injuries in male participants predominantly involve the lower back, whereas female amateur golfers are more likely to have problems with the elbow, wrist, or shoulder [6,7]. Low back injuries are also the most common injuries in male golf professionals, whereas wrist and hand injuries predominate in female golf professionals [8]. The golf swing is a high-torque and high lateral bending movement, for which the anatomy is poorly suited [9]. Further complicating this problem is the tendency for many beginning golfers to use maladaptive swing techniques that adversely affect kinetic forces on the trunk, shoulders, and * Corresponding author. University Rehabilitation, 450 Veterans Memorial Parkway, East Providence, RI address: jrp@urehab.necoxmail.com (J.R. Parziale) /06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi: /j.pmr pmr.theclinics.com

2 590 PARZIALE & MALLON legs. A study of 30 beginning golfers demonstrated a high prevalence of weight shift to the incorrect foot at the top of the backswing, a pattern that is increased with longer clubs, such as a driver [10]. Poor technique and overuse can lead to injury; most amateur golfers have injuries related to poor technique, whereas most injuries in professional golfers are caused by repetition and frequent practice [11]. The purpose of this article is to review the epidemiology, mechanism, and types of golf injuries and to outline appropriate medical and rehabilitation management options for the injured golfer. For additional information, the reader is referred to one of several textbooks on this subject [12 16]. Golf swing To have a complete understanding of the mechanics, muscle activity, and kinesiology of golf injuries, it is essential to have an understanding of the golf swing. The golf swing has five distinct stages: setup, backswing, transition, downswing, and follow-through (Fig. 1). Different muscle groups are firing at each of these phases [17 19]. For the purposes of this discussion, the golfer is assumed to be right-handed. Setup A comfortable, functional, and consistent setup is important for any golfer. The setup is the beginning point of the golf swing, and involves (1) a proper grip that allows the two hands to function as one unit and (2) an athletically prepared body position. There are multiple types and styles of golf grip, and these are described elsewhere [20]. The golfer s hips and knees are flexed at the starting point of the setup, known as the address position, and aligned in the direction of the target; the arms hang comfortably down from the shoulder, with the shoulders tilted approximately 15 with the left shoulder higher. The position of the golf ball is generally closer to the left foot and varies with the length of the club used so that the longer the club, the closer the ball position is aligned with the left heel at address. Backswing The backswing places the golfer and golf club in an optimum position to start the downswing. Ideally, the clubhead starts the backswing, with the shoulders and arms working together as a triangular pendulum, an action known as the take-away. Weight is shifted toward the right foot as the golfer rotates, in order, the knees, hips, and lumbar and cervical spine around a vertical axis. Electromyographic (EMG) studies of the upper extremities during this phase of the backswing demonstrate that most of the muscular activity during the backswing is isolated to the lower extremities and trunk and that the only substantial upper limb or trunk activity is in the subscapularis muscle of the left arm [19].

3 GOLF INJURIES & REHABILITATION 591 Fig. 1. Phases of the golf swing. (From Stover CN, McCarroll JR, Mallon WJ, editors. Feeling up to par: medicine from tee to green. Philadelphia: FA Davis; p. 19; with permission.) Transition Transition is the brief period at the top of the backswing when the lower body begins its downward rotation while the upper body and golf club continue rotating away from the golf ball. The transition begins when the golfer begins to shift weight back toward the left foot, allowing this high-torque motion to deliver additional kinetic energy to the golf ball. The transition is complete when the golf club has stopped moving away from the golf ball; at this point, the hips are rotated approximately 45 to the right

4 592 PARZIALE & MALLON from the address position, whereas the shoulders are rotated 90 to 100 to the right. This differential of 45 to 55 in upper trunk versus pelvic rotation at transition is known as the X-factor [21]. Downswing The downswing (including impact) is the portion of the golf swing that causes most golf injuries, and there are more than twice as many downswing injuries as backswing injuries [8]. As the downswing stage progresses, weight is shifted toward the left foot, as the hips move laterally and rotate, and the golfer pushes from the right foot toward the left, generating lateral and rotational torque on the lower back. At impact, the clubhead makes contact with an object (usually the ball or a piece of grass known as the divot but occasionally a nonyielding object like a root or a rock). EMG activity in the right quadratus lumborum, gluteal muscles, hamstrings, left triceps, latissimus dorsi, and wrist extensors is increased during this phase [18,22]. Follow-through Follow-through is a deceleration event and accounts for approximately one quarter of all golf swing injuries. After impact, the hips extend, the spine and shoulders rotate past the ball toward the left, the left forearm supinates, and the right forearm pronates. As the golf club decelerates, the lower back may be placed in hyperextension. Injuries Lower back The lower back is the most commonly and frequently injured area of the body in amateur and professional golfers. A thorough understanding of golfing low back injuries requires a familiarity with the mechanics of the golf swing and the anatomy of the spine as well as the evolution of the golf swing over the past century. The classic golf swing originated in Scotland and was made popular in the United States in the early 1900s with the use of a flexible hickory golf shaft. The classic swing style begins with a backswing using a relatively flat swing plane and a large hip and shoulder turn, with the hips turning almost as much as the shoulders. The modern swing, using a stiffer metal or graphite shaft, was refined in the latter half of the twentieth century. Like its predecessor, the modern swing uses a large shoulder turn but restricts the hip turn to build torque in the muscles of the lower back and shoulders. The modern swing has been advocated by many golf teaching professionals as a means of providing greater accuracy or distance by increasing the X- factor, the difference in the rotational angle formed by the shoulders versus the hips at the top of the backswing (transition) (Fig 2). Recent studies

5 GOLF INJURIES & REHABILITATION 593 Fig. 2. (A) Classic golf swing. At transition, the hips turn nearly as much as the shoulders and the follow-through ends with an upright posture. (From Stover CN, McCarroll JR, Mallon WJ, editors. Feeling up to par: medicine from tee to green. Philadelphia: FA Davis; p. 99; with permission.) (B) Modern golf swing. At transition, the shoulder turn is full, whereas the hip turn is restricted, and the follow-through ends with a lordotic spine posture. (From Stover CN, McCarroll JR, Mallon WJ, editors. Feeling up to par: medicine from tee to green. Philadelphia: FA Davis; p. 100; with permission.) refute the notion that an increased X-factor is required to produce maximal clubhead speed or driving distance [21]. The modern golf swing leads to greater angular displacement of the spine and is suspected as being a major source of injury for professional and amateur golfers. Mathematic models of the golf swing identify increased lateral bending, sheer, compression, and torsional forces at the L3 to L4 motion segment while swinging a golf club [12]; surface EMG examination of lumbar paraspinal muscles comparing male professionals and amateur golfers revealed that professionals demonstrated reduced peak lateral bending

6 594 PARZIALE & MALLON Fig. 2 (continued ) and sheer loads, with more efficient load production throughout a full range of motion [18]. Surface EMG activity reached 90% of peak muscle activity in the amateurs as compared with 80% for the professionals. In general, the professionals demonstrated a discreet on-and-off muscle firing pattern consistent with a grooved swing, whereas the amateurs demonstrated increased paraspinal muscle activity and lacked the professionals level of efficiency and precision. As well-trained clinicians are aware, low back pain can be multifactorial and may represent significant medical, orthopedic, or neurologic problems. Once the initial acute injury (or acute exacerbation of a chronic back problem) has been successfully treated, it is essential that the golfer optimize his or her flexibility and strength in the spine, legs, and shoulders. Research on the X-factor performed by our group and others has demonstrated the need for a high level of flexibility at the hips and shoulders in older golfers [21].

7 GOLF INJURIES & REHABILITATION 595 The anterior and posterior trunk muscles stabilize the spine, and improving the function of these muscle groups is an important part of any low back rehabilitation program. Because the golf swing involves rotation around a spinal axis and EMG studies demonstrate a rapid on-off phase of muscular contraction, low back rehabilitation programs for golfers should include exercises for fast-twitch and slow-twitch muscle fiber contraction. Dynamic functional strengthening programs using a Swiss ball and plyometric exercises are often advocated for advanced players. Strengthening exercises for the latissimus dorsi and hamstrings are also important [17]. Golf swing modifications include the use of an athletic position at address with proper flexion of the hips and knees, and adoption of a classic swing style in which the hips are rotated along with the shoulders helps to reduce the torsional stress on the lower back imposed by the modern coiled swing at transition. Warming up before the round and a gradual cooldown phase after play are also helpful in reducing injury. Using a long putter helps to reduce the degree of thoracolumbar kyphosis and improve the spine angle (Fig. 3), and pushing a cart produces less torque on the spine as compared with pulling a cart (Fig. 4). Upper limb As compared with other sports, golf does not require a high degree of humeral elevation or rotation and may not truly be considered an overhead sport. This is reflected in the relatively lower incidence of shoulder injuries in golfers. Repetition or overuse can be a risk factor for shoulder injuries, particularly in older golfers. A high volume of repetition can cause the soft tissues about the shoulder to become inflamed. Coupled with impaired circulation to the rotator cuff, senior golfers can be particularly prone to shoulder pain caused by bursitis or rotator cuff injuries. In younger golfers (ie, those less than 35 years of age), joint laxity or a high-velocity swing can cause excessive microtrauma to the rotator cuff mechanism. Fig. 3. Postural effects of using short, average, and long putters.

8 596 PARZIALE & MALLON Fig. 4. (A) Pulling a golfcart. (B) Pushing a golfcart. The mechanics of the golf swing may give potential clues as to the cause of these injuries. The nondominant or lead arm (ie, the left arm in a righthanded golfer) is more commonly involved. At the top of the backswing, the lead arm is in maximal adduction and pain can often develop at the lead acromioclavicular joint. Posterior capsulitis or a tight posterior shoulder joint capsule may be a cause of posterior shoulder pain at the top of the backswing. During the downswing, scapular muscles are important in building velocity. If these muscles are weak, a stable base cannot be provided and interscapular pain can develop. During follow-through, the lead humerus is abducted and externally rotated, with contraction of the rotator cuff musculature and stress on the inferior labrum of the glenohumeral joint. Conversely, the dominant arm is more likely to develop shoulder pain because of an impingement syndrome at the top of the backswing and particularly during the phase of transition when the arms and hands are moving in an opposite direction from the hips and trunk. EMG studies of the shoulder during the golf swing demonstrate that rhomboid and trapezius muscle activity is increased on the right during the backswing and on the left during follow-through. Serratus anterior activity is greatest during the downswing and early follow-through, and linked biscapular motion is present during the golf swing [22]. Rehabilitation of shoulder injuries is dependent on the correct diagnosis, including a determination of whether the injury is related to restricted range of motion or joint laxity and whether nonoperative or operative intervention was used. Recommendations for golf swing modification can also vary with the diagnosis; the patient with a rotator cuff injury with impingement may be advised to flatten his or her swing, whereas the patient with acromioclavicular joint arthritis could adopt a more upright swing [23]. Most clinicians would agree that strengthening of key muscle groups, including the rhomboids, rotator cuff, latissimus dorsi, and triceps, is important to good shoulder health. A study of 29 recreational golfers undergoing arthroscopic rotator cuff repair found that 90% returned to pain-free golf and were able to play at the same or a similar competitive level, based on their average best score (known as a golf handicap index) [24]. For individuals with persistent arthritic

9 GOLF INJURIES & REHABILITATION 597 shoulder pain refractory to conservative measures, joint replacement surgery may become necessary to reduce pain and allow a return to functional activities, including golf. As noted in the section on low back injuries, a preround warm-up session is important and should include flexibility exercises for the shoulders, especially the pectoral muscles and posterior joint capsule. Elbow Medial epicondylitis of the dominant arm is commonly referred to as golfer s elbow, but numerous studies demonstrate that lateral epicondylitis (tennis elbow) of the lead arm is at least four times more likely to occur [8,25]. Overuse during excessive practice or impaired strength of the forearm muscles may play a role in the development of epicondylitis, and women are more likely to develop golf-related elbow pain than men [6]. Wrist and hand Pain at the ulnar side of the palm of a golfer s hand should lead the clinician to suspect a fracture of the hamate. Hamate hook fractures may occur secondary to trauma while using a long-handled implement and most commonly occur in the hand grasping the end of the club (the left hand in a right-handed golfer). Pain may be reproduced with palpation of the dorsoulnar aspect of the wrist or may be precisely located over the hamate with applied pressure. Pain is often worsened when gripping or swinging a club. Radiographs may be inconclusive, and a CT scan may be required to make the diagnosis. Treatment for hamate hook fractures may involve surgical removal of the fractured hook, because a large number of these fractures treated with immobilization fail to heal [26,27]. A bicycle rider s glove on the left hand can be used to pad the hypothenar eminence and reduce pain at impact. Tendinitis of the wrist and hand commonly occurs in the lead hand during the golf swing and can be caused by excessive cocking of the left wrist on the backswing; rapid deviation of the wrist(s) at impact; or sudden deceleration at impact when the club strikes a rock, root, or turf. Extensor pollicis longus tendinitis (De Quervain s tenosynovitis), extensor carpi ulnaris tendinitis, or flexor carpi radialis or flexor carpi ulnaris tendinitis can occur during the golf swing and are seen more frequently in female golfers than in male golfers. A strong grip position, in which the hands are rotated clockwise on the club handle, may increase the likelihood of wrist tendinitis. Carpal tunnel syndrome (CTS) is a common clinical disorder and can be caused by multiple factors, including occupational or recreational overuse. Although golf has not been identified as a direct cause of CTS, repetitive use of the wrists and hands while playing golf may contribute to the symptoms of this disorder. CTS can be disabling for a golfer; US Open champion Ken Venturi developed severe CTS in both hands that effectively ended his playing career [12].

10 598 PARZIALE & MALLON After appropriate diagnosis and clinical treatment, modification of equipment or the golf swing can reduce the tendency to develop problems with the wrist and hand. Oversized grips that are generally larger and softer help to reduce the compressive force pressure necessary to hold a club. Golf grips should be replaced every 40 to 50 rounds to reduce slipping, and some players may find it helpful to use a glove on each hand. Correctly fitted golf clubs have the butt end of the club handle extend approximately 1 inch beyond the hypothenar eminence of the left hand; clubs that are too short put pressure against the hook of the hamate bone, placing it at risk for fracture. Golfers should reduce the grip pressure at address and avoid using the strong grip position by rotating the left hand counterclockwise. Swing modifications include avoidance of excessive wrist motion at take-away or transition and adopting a flat or more elliptic swing plane in which the hands are kept at or near shoulder height during transition and at the completion of follow-through. This allows the golf ball to be swept off the turf and may help to reduce the likelihood of wrist and hand injuries. There is no definitive evidence that graphite golf shafts or low-compression golf balls have any real effect on hand, wrist, or elbow injuries. Lower limb Injuries to the hip while playing golf are uncommon (1% in professionals and 3% in amateur golfers) [6,8], but hip pain in senior golfers is a common event. Hip pain in golfers is often related to arthritis, although sprains and strains can also be seen. McCarroll [28] reported inflammation of the trochanteric bursa, iliotibial band, or tensor fascia lata in female golfers seen in his clinic, and most were treated conservatively. Although golf may not be the cause of knee injuries, playing golf may aggravate preexisting knee problems. Walking the course, flexing the knees at address or to pick up a tee or ball, and rotating the knees during the golf swing can all lead to injury. The most stressful phase of the golf swing is during the downswing, and the lead (left) and trailing (right) knees are affected with equal frequency. Knee pain can be increased with long-distance shots; using clubs for short distances, including short irons or pitching wedges, is less likely to cause knee pain, and the advent of spikeless golf shoes may have reduced torsional stress leading to knee pain in golfers [29]. Adopting an athletic knee flexion posture with slight external rotation of the feet at address and a smooth flowing golf swing, coupled with a regular program of strengthening and flexibility exercises for the hip rotators, quadriceps, hamstrings, and gastrocnemius, would be sensible advice for most golfers with hip or knee pain. Head and neck Head and neck injuries in golfers are infrequent but have been reported. Most are related to blunt trauma caused by a ball, but a penetrating injury

11 GOLF INJURIES & REHABILITATION 599 of the neck caused by a splintered golf club shaft caused carotid laceration and death [30]. Golfers who report posterior lower neck and upper back pain while carrying a golf bag on one shoulder may be advised to use a double strap (ie, a strap placed over each shoulder) to reduce retraction and downward rotation force on a single scapula or periscapular muscle group. Another option is the use of a golf pushcart in lieu of carrying a golf bag. Special considerations Cardiac Golf is enjoyed by young and old alike, and there are clear cardiovascular benefits of this sport. Energy consumption while walking a golf course and carrying a golf bag is 375 calories per hour [31], and walking a hilly course while carrying a bag compares favorably with an aerobic workout [32]. Golfers who walk the course and play at least three times per week (walking 12 to 15 miles) during the golf season improve their total cholesterol levels and high-density lipoprotein (HDL)/low-density lipoprotein (LDL) ratios [33]. In the United States, more than 250,000 people die annually as a result of cardiac arrest before reaching a hospital. The fifth likeliest public location in the United States at which to collapse from sudden cardiac arrest is the golf course [34]. The cardiac arrest victim s chance of survival decreases at least 10% for each minute without treatment, and many golf courses have obtained an automatic external defibrillator (AED). Skin Golf is a game played outdoors, and exposure to the sun, plant toxins, and insect bites is part of the game. The skin is the largest organ of the body and provides a barrier against bacteria and protects against dehydration and extreme temperature variation. Sunscreen, a wide-brimmed hat, and clothing with a tight weave help to protect against sunburn and skin cancer. Certain medications may increase sensitivity to UV light and should be used with caution, including antibiotics (eg, sulfonamides, tetracycline, trimethoprim), diuretics (eg, thiazides, furosemide), nonsteroidal antiinflammatory drugs (NSAIDs) (eg, aspirin [ASA], ibuprofen, naproxen), cardiac medications (eg, diltiazem, nifedipine), and diabetic medications (sulfonylurea). Golfers should periodically check their skin for signs of cancer, which include the ABCDs (asymmetry, irregular border, variable color, and diameter O6 mm) proposed by the American Academy of Dermatologists. Contact dermatitis can occur as a result of contact with plants like poison ivy, poison oak, or poison sumac. Prevention is key (the poison ivy adage, leaves of three, let them be, applies); cold running water applied quickly after contact and application of a hydrocortisone ointment are effective in most cases.

12 600 PARZIALE & MALLON Lyme disease was first identified in 1975 and is spread by the deer tick. Borrelia burgdorferi is the infecting agent; symptoms may include a red bull s-eye or reticuloform rash, fever, flu-like symptoms, fatigue, arthralgias, arthritis, and neuropathy. Prevention requires the use of a repellent spray containing N,N-diethyl-meta-toluamide (DEET) before walking in the woods or tall grass, with skin inspection and careful removal of the tiny deer tick from the skin and application of a topical antibiotic. Symptoms of Lyme disease may occur for up to 8 weeks after infection; screening or diagnostic blood tests are available. Treatment includes intravenous or oral antibiotics. Other diseases transmitted by ticks include Rocky Mountain spotted fever and ehrlichiosis. Golf courses are often treated with neurotoxic pesticides and chemicals, and chemical sensitivities can be problematic for many golfers. Fire ants, bees, and wasps are common, and golfers with known allergic reactions should carry injectable epinephrine and inform their playing partners of its location before play. Snake or spider bites are potentially fatal and require emergency medical treatment. Eye With increased age comes changes in vision, and this is certainly true for golfers. Corrective eyewear must be chosen carefully, because bifocals can result in visual distortion, contact lenses may trap dust or dirt, and even the color or tint of sunglasses can affect depth perception. Prolonged sun exposure may cause cataracts or retinal damage. Nearly 90% of harmful UV- B rays can be reduced or eliminated depending on the quality, tint, and shape of sunglass lenses. Although uncommon, direct trauma to the eye or orbit can occur as a result of a struck ball or thrown club. Pregnancy Anatomic changes that occur during pregnancy may cause an alteration in a woman s golf swing but do not necessarily prevent play. There are multiple examples of amateurs and Ladies Professional Golf Association (LPGA) Tour players competing at a high level; helpful adaptations for physiologic changes include flattening the swing plane or shortening the length of the putter, maintaining hydration because of lower extremity vasodilatation, and anticipating the need for frequent urination. Treatment options for the musculoskeletal complications of pregnancy were recently reviewed [35]. Arthroplasty and postoperative considerations Many seniors are afflicted with arthritic conditions of the hip and knee, and total joint replacement surgery (arthroplasty) is a treatment often used to reduce pain and increase function. A prominent orthopedic surgeon noted that golf is the most often cited functional goal for hip or knee

13 GOLF INJURIES & REHABILITATION 601 replacement in my patient population [36]. There are many examples of golfers who play at the highest professional levels after total joint replacement, including Jack Nicklaus, arguably the greatest golfer ever, and others on The Champions Tour. Although some authors have suggested that increased patient activity levels may have an adverse affect on implant durability, surveys of the members of the Hip Society and the Knee Society revealed that no member thought that total hip replacement was a contraindication to playing golf and all concurred that those patients who desired to play golf after total hip arthroplasty were able to do so [37]. No specific guidelines for a return to golf were developed, but most patients returned to golf 3 to 4 months after hip arthroplasty and some patients returned as soon as 4 weeks after surgery. Some orthopedic surgeons did advise golfers with cementless hip prostheses to limit their golfing activity for a period of 6 to 8 months after surgery if they felt thigh pain while playing golf [36]. Although 93% of the members surveyed thought that a total knee replacement was not a contraindication to playing golf, 7% counseled their patients against playing golf after knee arthroplasty. The Hip and Knee Society members varied in their opinions on the need for use of a golf cart after joint replacement surgery, with a slightly higher percentage of orthopedic surgeons recommending cart use for knee replacement patients than for hip replacement patients (77% versus 69%). A study of 24 patients who had shoulder arthroplasty revealed that 23 were able to resume playing golf. The average time from shoulder arthroplasty to playing a full round of golf was 4.5 months, and 18 of these patients reported a postoperative improvement in their golf score by an average of nearly five shots per round [38]. In a review of 273 total shoulder arthroplasty patients, 23 were avid golfers and tennis players. There was no radiographic evidence of loosening within this subset of patients. Many shoulder arthroplasty patients indicated a concern for their level of recreational activity, and although there is no specific contraindication to playing golf after shoulder arthroplasty, some physicians advise their patients to tee the ball up in all areas to prevent potential stress on the shoulder joint. Waiting time to attempt a return to golf should be at least 12 weeks, or until the patient has regained preoperative range of motion. The opinions of some joint replacement surgeons are less favorable when it comes to total elbow arthroplasty, however, and some elbow surgeons prohibit activities that generate greater than 5 to 10 lb of force across the elbow joint [37]. Physically challenged golfers Golf can be of significant value physically and psychologically to individuals who are physically challenged, including those who have a partial limb amputation. After losing his own leg in World War I, Ernest Jones, a British teaching professional, developed many of his theories on the golf swing.

14 602 PARZIALE & MALLON In the United States, the National Amputee Golf Association (NAGA) was incorporated in This organization has grown to more than 2500 members, with affiliate organizations in 17 other countries, including Japan, Great Britain, and Australia. In 1984, the NAGA successfully persuaded the United States Golf Association (USGA) to allow the use of modified prosthetic devices in competition [39]. The NAGA sanctions a series of golf competitions across the United States each year and attracts participants from around the world (more than 180 persons registered for the 2005 NAGA competition at Bethpage Golf Course in New York.) To provide equity within these competitions, multiple divisions have been established according to the type of impairment, including above knee; below knee; above elbow; below elbow; and double, triple, and quadruple amputations. There are divisions for men, women, and juniors. In the world of professional golf, Casey Martin is an accomplished professional golfer who earned the right to play on the Professional Golf Association (PGA) Tour after successfully completing a series of sanctioned competitions. Physically challenged by a congenital vascular condition known as Klippel-Trenaunay-Weber syndrome, a progressive circulatory disorder that prevents him from being able to walk for long distances, Martin requested the use of a motorized golf cart in PGA Tour events after using a cart in sanctioned qualifying competitions. This request was denied by the PGA Tour, and the PGA Tour s denial was overruled by the United States Supreme Court in a landmark case in 2000, citing Title III of the Americans with Disability Act (ADA) [40]. The Champions (aka Senior) Tour disallowed the widespread use of motorized carts by its competitors in January 2005 but has subsequently lifted that ban. The USGA has allowed medical exemptions for physically challenged individuals to use motorized golf carts in sanctioned competitions. In September 2005, Derek Gammet became the first individual with cerebral palsy to pass the PGA of America s Playing Ability Test, the first step to becoming a teaching golf professional [41]. Although golf is not a common wheelchair sport, there are many examples of adaptations made by and for paraplegic or quadriplegic golfers. The First Swing program supports accessible golf by providing more than day or 2-day beginners clinics for health care professionals and physically challenged persons each year and is cosponsored by the NAGA and USGA (Fig. 5). Golf courses specifically designed for accessibility can be found in at least 13 states. Single-rider golf carts with tires that place less than 7 psi on a putting surface (less than that of a 180-lb person s foot) allow personal independence, can be used throughout the golf course, and have been endorsed by the Golf Course Superintendent s Association. One such device features hand controls and a 350 rotating seat that can elevate and tilt the player into standing position if desired. In 1984, the USGA allowed the use of orthotic or prosthetic devices in competition (Rule 14-3/15) [39]. Dennis Walters is a PGA professional who was paralyzed in a golf-cart accident and now demonstrates his ability as a trick-shot artist, hitting

15 GOLF INJURIES & REHABILITATION 603 Fig. 5. Bilateral transtibial amputee golfer. (Courtesy of the NAGA and S. Satoh, Amherst, NH). golf balls while partially seated on a golf cart. Adapted wrist-hand orthoses can allow some quadriplegic golfers to play from a motorized cart [42]. Visually impaired golfers have their own organization, the Blind Golfers Association, and also compete in tournaments with special rules sanctioned by the USGA. Visually challenged golfers may use a coach who can adjust the stance or alignment of the player, and the visually challenged golfer s club or cane is allowed to touch the ground in a hazard without penalty. Rehabilitation Proper treatment of golf injuries begins with a thorough history and physical examination of the patient, along with an evaluation of that person s golf swing. A multidisciplinary program that includes a clinical examination by a physiatrist and physical therapist as well as a videotaped golf swing assessment by a PGA professional has been previously described [7]. Sports medicine principles are applied to the golfer s injury, including a gradual progression from management of the acute injury or inflammatory process; recovery of normal range of motion, strength, and endurance; and, finally, sport-specific rehabilitation. In our experience, many amateur golfers also required golf swing modification, because aberrancies or idiosyncrasies of the particular golf swing made those individuals more prone to injury, and a PGA professional has been an invaluable member of the treatment team. Modification of the golf swing should be appropriate to the physical impairment in a physically challenged individual. Examples include external

16 604 PARZIALE & MALLON rotation of the hips in the patient after total hip or knee replacement, flattening of the swing plane in the golfer with a shoulder impingement syndrome, or elevation of the forward heel at transition (top of the backswing) in the golfer with low back pain. Fitness and wellness Flexibility, strength, and aerobic training have become increasingly popular among golfers over the past several decades [17]. Early advocates of strength training included Gary Player, the international champion who claimed to have significantly increased the length of his drives despite his small physical stature. More recently, players like Tiger Woods have embraced strength and flexibility training and have undertaken regular fitness training programs, whereas more senior players have been exercising to improve their level of play or merely to remain competitive with younger players. Several studies of strength and flexibility training reproduced our finding that an 8- week program of exercises, performed three times per week, could significantly improve physical parameters and golf clubhead speed [21]. A mobile fitness trailer that includes physical therapists or personal fitness trainers can be Fig. 6. (A) Posterior shoulder capsule stretch. (B) Wrist extensor stretch. (C) Trunk rotator stretch. (D) Hamstring stretch. (E) Quadriceps stretch.

17 GOLF INJURIES & REHABILITATION 605 found at many professional golf tour stops and is a valuable asset in performance enhancement. Prevention and treatment of most golf injuries begin long before arriving at the golf course. A regimen of flexibility and strengthening exercises, coupled with proper swing technique, may reduce the likelihood of future injury. Once you arrive at the golf course, a series of stretching exercises before practice and play is encouraged; our series of exercises was published in a national golf magazine in 1996 (Fig. 6) [43]. Nutrition on the golf course can be important, particularly for the diabetic golfer. Simple sugars may cause fluctuations in blood glucose level and should be avoided. Caffeinated beverages can cause tremors or palpitations. Alcohol should always be avoided during play. Many top players have used the assistance of a sports psychologist to help improve performance. The best-known psychologic affliction among golfers is termed the yips, a jerky putting stroke that lacks rhythm and coordination and affects many golfers as they become older. Visualizing a target or desired result and seeing the correct swing before it occurs, with a focus on a positive outcome, are commonly used techniques. Basic sports psychology principles are applied: (1) golfers cannot control all the events that happen to them but they can control their response to these events, and (2) golfers cannot control performance until they learn to control their thoughts and emotions [44]. Summary There are more than 25 million golfers in the United States, and many have an injury related to golf. Low back injuries are the most common golf injuries, followed by elbow injuries. Successful treatment of golf injuries often includes modification of the golf swing. Adaptations allow many individuals, including those who are physically challenged, to enjoy playing golf. References [1] Werner D. Driving toward prevention. Phys Ther Prod 2000;5:12 5. [2] Stover C, Stoltz J. Golf for the senior player. Clin Sports Med 1996;15: [3] National Safety Council. Annual report. Itasca (IL); [4] Wilks J, Jones D. Golf related injuries seen at hospital emergency departments. Aust J Sci Med Sport 1996;28:43 5. [5] Batt ME. A survey of injuries in amateur golfers. Br J Sports Med 1992;26:63 5. [6] McCarroll JR. Injuries in the amateur golfer. Phys Sportsmed 1990;18: [7] Parziale JR. Healthy swing: a golf rehabilitation model. Am J Phys Med Rehabil 2002;81: [8] McCarroll JR, Gioe TJ. Professional golfers and the price they pay. Phys Sports Med 1982; 10:54 70.

18 606 PARZIALE & MALLON [9] Stover CN, Wiren G, Topaz SR. The modern golf swing and stress syndrome. Phys Sportsmed 1976;4:42 7. [10] Koslow R. Patterns of weight shift in the swings of beginning golfers. Percept Mot Skills 1994;79: [11] McCarroll JR. The frequency of golf injuries. Clin Sports Med 1996;15:1 7. [12] Stover CN, McCarroll JR, Mallon WJ. Feeling up to par. Philadelphia: FA Davis; [13] Foster L. Dr. Divot s guide to golf injuries. North Salem (NY): Doctor Divot Publishing; [14] Palank E. The golf doc. Boston: Jones & Bartlett; [15] Guten GN, editor. Clinics in sports medicine: golf injuries. Philadelphia: WB Saunders; [16] Mallon W. The golf doctor. New York: MacMillan; [17] Wolkodoff N. Physical golf. Denver: KickPoint Press; [18] Hosea TM, Gatt CJ, Galli NA, et al. Biomechanical analysis of the golfer s back. In: Cochran AJ, editor. Science and golf: proceedings of the First World Scientific Congress of Golf. London: E & FN Spon; p [19] Moynes DR, Perry J, Antonelli DJ, et al. Electromyography and motion analysis of the upper extremity in sports. Phys Ther 1986;66: [20] Palmer A. My game and yours. New York: Simon & Schuster; [21] Westcott WL, Parziale JR. Golf power. Fitness Management 1997;13: [22] Kao JT, Pink M, Jobe FW, et al. Electromyographic analysis of the scapular muscles during a golf swing. Am J Sports Med 1995;23: [23] Mallon WJ, Colosimo AJ. Acromio-clavicular joint injury in competitive golfers. J South Orthop Assoc 1995;4: [24] Vives M, Miller L, Rubenstein D, et al. Repair of rotator cuff tears in golfers. Arthroscopy 2001;17: [25] Mallon WJ. How to cure and prevent golfer s elbow. Golf Digest 1998;48: [26] Stark HH, Chao EK, Zemel NP. Fracture of the hook of the hamate. J Bone Joint Surg [Am] 1989;71: [27] Aldridge JM, Mallon WJ. Hook of hamate fractures in highly competitive golfers. Orthopaedics 2003;26(7):1 3. [28] McCarroll J. The lower extremity. In: McCarroll J, Stover CN, Mallon WJ, editors. Feeling up to par. Philadelphia: FA Davis; p [29] Guten G. Knee injuries in golf. Clin Sports Med 1996;15: [30] Schulenberg C. Medical aspects and curiosities of golfing. Practitioner 1976;217: [31] Dobrosielski DA, Brubaker PH, Berry MJ, et al. The metabolic demand of golf in patients with heart disease and in healthy adults. J Cardiopulm Rehabil 2002;22: [32] Unverdorben M, Kolb M, Bauer U, et al. Cardiovascular load of competitive golf in cardiac patients and healthy controls. Med Sci Sports Exerc 2000;32: [33] Palank EA, Hargraves EH. Benefits of walking the golf course: effects on lipoprotein levels and risk ratios. Phys Sportsmed 1990;18: [34] Becker L, Eisenberg M, Fahrenbruch C, et al. Public locations of cardiac arrest. Circulation 1998;97: [35] Borg-Stein J, Dugan S, Gruber J. Musculoskeletal aspects of pregnancy. Am J Phys Med Rehabil 2005;84: [36] Mallon WJ, Callaghan JJ. Total hip arthroplasty in active golfers. J Arthroplasty 1992; 7(Suppl): [37] Mallon WJ. The golfer with a total joint replacement. In: Stover CN, McCarroll JR, Mallon WJ, editors. Feeling up to par: medicine from tee to green. Philadelphia: FA Davis; p [38] Jensen KL, Rockwood CA. Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg 1998;7(4):362 7.

19 GOLF INJURIES & REHABILITATION 607 [39] United States Golf Association. A modification of the rules of golf for golfers with disabilities. Far Hills (NJ): United States Golf Association; [40] PGA TOUR, Inc. v. Martin. Supreme Court of the United States No [41] Gemmet D. PAT answer. Sports Illustrated 2005;103:G16. [42] Gordon S, Levier D, Sachse R, et al. Adaptive device for the quadriplegic golfer. Arch Phys Med Rehabil 1985;66: [43] Horwich R. Loosen up. Senior Golfer Magazine 1996;4: [44] Rotella R. Golf is not a game of perfect. New York: Simon & Schuster; 1995.