THE INJURY PATTERNS OF HONG KONG AMATEUR GOLFERS WAN SIU MING TIMOTHY

Transcription

1 THE INJURY PATTERNS OF HONG KONG AMATEUR GOLFERS BY WAN SIU MING TIMOTHY AN HONOURS PROJECT SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF BACHELOR OF ARTS IN PHYSICAL EDUCATION AND RECREATION MANAGEMENT (HONOURS) HONG KONG BAPTIST UNIVERSITY APRIL 2012

2 HONG KONG BAPTIST UNIVERSITY 30 APRIL, 2012 We hereby recommend that the Honours Project by Mr. Wan Siu Ming Timothy entitled THE INJURY PATTERNS OF HONG KONG AMATEUR GOLFERS be accepted in partial fulfillment of the requirements for the Bachelor of Arts Honours Degree in Physical Education And Recreation Management. Dr. LOUIE Lobo Chief Advisor Dr. LAU Patrick Second Reader

3 DECLARATION I hereby declare that this honours project THE INJURY PATTERNS OF HONG KONG AMATEUR GOLFERS represents my own work and had not been previously submitted to this or other institution for a degree, diploma or other qualification. Citations from other authors were listed in the references. WAN Siu Ming Timothy 30 April, 2012

4 ACKNOWLEDGEMENTS I would like to express my deepest gratitude to my chief advisor, Dr. LOUIE Lobo, for his professional advises and guidance throughout the period of study. I would also like to thank Dr. LAU Patrick to be the second reader of the study. Last, but not least, thanks to the amateur golfers who participated in the study and provided the necessary information for the research process. WAN Siu Ming Timothy 30 April, 2012

5 ABSTRACT Golf is a sport which is believed to be mild and without strenuous muscle movements. Therefore, it is also thought to be less risky in getting injuries through participation. However, the risk to be injured during a round of golf, or even practicing on the driving range was underestimated by the public and the golfers. This study was carried out to investigate the injury patterns of local Hong Kong amateur golfers. It was also one of the aims of this study to examine the relationship between golf injury patterns and possible variable factors, such as age, gender, and playing levels of golfers. In the study, 224 amateur golfers were randomly selected a self-designed questionnaire to enquire their injury patterns in the past 12 months. It was found that 92 out of 224 respondents (41.1%) reported injuries in the period. A total of 214 injuries were recorded. In average, each golfer sustained 2.33 injuries in a year.

6 The vast majority of the injuries were strains, while the most common injury reported was golfer s elbow (medial epicondylitis), followed by lower back strain and shoulder strain. Upper extremities of the golfers suffered more injuries than other anatomical regions of the golfers. As for specific body parts, it was found that most golfers injured their lower back, wrist and hand, and shoulders. It is believed that with the rising popularity of golf in Hong Kong, it is important to golfers to be alarmed of the risk of injuries when playing the game, and should take preventive measures such as warm-up exercises and supplementary fitness trainings to avoid golf injuries.

7 TABLE OF CONTENTS CHAPTER PAGE 1 INTRODUCTION 1 Statement of Problem 3 Hypotheses 3 Definition of Terms 4 Delimitations 5 Limitations 5 Significance of Study 6 2 REVIEW OF LITERATURE 7 Incidence Rate of Golf Injuries 7 Common Anatomical Sites of Golf Injuries 9 Types of Golf Injuries 12 Causes and Aetiology of Golf Injuries 14 Factors Influencing Golf Injury Pattern 15 Summary of Review of Literature 20 3 METHOD 22 Subjects 22 Instrument 23

8 Procedures 23 Data Collection 24 Data Analysis 25 4 ANALYSIS OF DATA 26 Results 28 Discussion 59 5 SUMMARY AND CONCLUSION. 72 Summary of Results 72 Conclusion 74 Recommendation for Future Studies 75 REFERENCES 77 APPENDIX 81 A. Golf Injury Questionnaire (Chinese Ver.) 81 B. Golf Injury Questionnaire (English Ver.) 83

9 LIST OF TABLES TABLE PAGE 1 Gender Distribution of Respondents 28 2 Age Distribution of Respondents 29 3 Handicap Distribution of Respondents 29 4 Exposure time in golf activities of respondents Hours in Supplementary training of respondents 32 6 Warm-up Frequency of Respondents 32 7 Kinds of Warm-up Exercises Performed by Respondents 33 8 Types of Warm-up Performed by Respondents 34 9 Summary of Injury Patterns Gender Differences in Injury Patterns Injury Pattern Across Different Age Groups Injury Information for Different Handicap Groups Types of Golf Injuries Chi square Test for Differences between Variables and Injury Frequency Pearson Correlation between Variables and Injury Frequency Causes and Aetiology of Golf Injuries Treatments of Golf Injuries 54

10 18 Recovery Time Required Respondents Belief in Own Injury Prevention Knowledge Preventive Measures Supported by Golfers 58

11 LIST OF FIGURES FIGURE PAGE 1 Types of Warm-up Performed by Respondents 34 2 Frequencies of Injuries Suffered 38 3 Frequencies of Injuries Suffered by Anatomical Body Parts 38 4 Percentages of Injuries suffered by Anatomical Regions 39 5 Injuries Suffered by Different Gender Groups 41 6 Injuries Suffered by Different Age Groups 43 7 Injuries Suffered by Different Handicap Groups 46 8 Types of Golf Injuries 47 9 Causes and Aetiology of Golf Injuries Treatments of Golf Injuries Recovery Time Required Preventive Measures Supported by Golfers 58

12 1 CHAPTER 1 INTRODUCTION Background of Study Nowadays, golf is a popular sport which suits people from different ages, gender, and playing levels. There are over 60 billion golfers in around 100 countries and regions. It is believed that golf is a non-strenuous physical activity which can improve individuals health. Golf is a sport which was introduced to Hong Kong for over 100 years. The Hong Kong Golf Club, which was the first golf club in Hong Kong, was formed in 1889 and is among the 100 oldest golf clubs in the world. Although the sport was introduced to the region for so many years, the sport remained at low participation rate as it was limited to higher-class groups. It was because of its relatively higher cost and the membership policy of private golf clubs. Golf started to gain popularity among local citizens in the 1980s, when the government built the first public driving

13 2 range in Tuen Mun. And in 1995, the first public golf course, Jockey Club Kau Sai Chau Public Golf Course, was built and provide opportunities for citizens to play on a golf course in a bargaining price. Also, with the fast development of the mainland China, many golf courses were built in the Guangdong province, and attracted Hong Kong golfers to increase their participation in golf activities. (Louie, 2010) Although the game is thought to be mild, there still exists the risk of being injured during golf activities due to different kinds of reasons. With the increasing popularity of golf, it would be necessary for golfers to know the probability of golf injuries and hopefully preventive measures can be set up so as to prevent injuries.

14 3 Statement of Problem The objective of the study is to identify injury patterns of Hong Kong golfers during participation in golfing activities. It is also aimed to find out whether there are correlations between golf injuries and factors such as age, gender, warm-up pattern and playing level. Hypotheses 1. Golf injuries occur often due to overuse of a particular body position. 2. Most of the injuries occur at lower back, elbow and shoulders of amateur golfers. 3. The most common type of golf injuries would be strains. 4. Golfers of different age groups will have differences in major sites of golf injuries. 5. Gender will not be an influencing factor in golf injuries. 6. Golfers with higher handicap (less skilled) will be more likely to have golf injuries. And difference in playing level will also lead to difference in injured sites.

15 4 Definition of Terms Sports injury Sports injury is defined as the kinds of injury infected to a person during participation of sports or exercise. It may be resulted from reasons such as accidents, poor training practices, lack of conditioning, or insufficient warm-up and stretching, and improper equipment. (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2009). Handicap Index It is issued to a golfer by a golf club or an authorized golf association to indicate the golfer s skill level. It is a number taken to one decimal place which is calculated according to a formula set by the USGA, with the consideration of the recent 10 best scores out of 20 of the golfer. (United States Golf Association, 2008) Amateur golfer Except the Rules of Golf is provided, an amateur golfer plays the game of golf purely as a sport, without receiving

16 5 remuneration or making profit from the game. And an amateur golfer also does not receive remuneration from teaching golf or for other activities because of the individual s skill, knowledge and reputation in golf. (United States Golf Association, 2008) Delimitations The followings are the delimitation of this study: 1. Subjects are delimited to male and female amateur golfers, who were Hong Kong residents, aged 18 or above. 2. Subjects are delimited to players who regularly participate in golf activities at least once per week. 3. Incidence of injuries is delimited within the past year. Limitations The following limitations should be considered before interpreting the results in the study: 1. The reliability of questionnaire was limited as it was self-designed. 2. It was assumed that the subjects were able to understand

17 6 vocabularies used in the questionnaire. 3. It was assumed that the subjects acquire the knowledge to identify the kinds of their injuries. 4. It was assumed that the subjects answered the questionnaire honestly. Significance of Study The significance of the study is to provide an overview of the golf injury pattern among Hong Kong golfers. It would suggest if there were any correlations between golf injuries and different factors, including age, gender, and skill level of golfers. And the study would like to find out the reasons behind golf injuries. It is hoped that the findings of the study could facilitate coaches and golfers in organizing training programs which implement preventive measures to prevent injuries.

18 7 CHAPTER 2 REVIEW OF LITERATURE In this review of literature, it was divided into four sections: i) Incidence Rate of Golf Injuries; ii) Common Anatomical Sites of Golf Injuries; iii) Types of Golf Injuries; iv) Causes and Aetiology of Golf Injuries; v) Factors Influencing Golf Injury Pattern; and vi) Summary of Review of Literature. Incidence Rate of Golf Injuries Unlike other sports such as basketball and soccer, golf appeared to be a sport without much physical exertion and intense body contact with opponents. It was thought that the risk of getting injured was low through participation in golf. In fact, the injury rate in golf was underestimated. In 1992, Batt did a survey to assess golf injury patterns of amateur golfers. In his study, he classified golf injuries

19 8 into two groups, namely actual injuries and incidental injuries. Actual injuries were referred to injuries received while playing golf, such as struck by ball, blisters, bee stings, and others. As for incidental injuries were those which related to other ailments in an individual s golf activities. The study interviewed 193 amateur golfers and found out that 57% of the suffered from actual and/or incidental golf injuries. Besides, among all the interviewees, 32% suffered from actual injuries and 42% of them suffered from incidental injuries. Though Batt reported an injury rate of over 50% in the study in 1992, most of the following studies conducted found the injury rate ranges around 30% to 40% of the studied population. In 2003, Gosheger, Liem, Ludwig, Greshake, and Winkelmann surveyed 643 amateur golfers in their study, 255 respondents (39.7%) reported 527 injuries, which also provided an injury rate of 2.07 injuries per player. The study of Fradkin, Cameron, and Gabbe in 2005 found that among the

20 9 522 female golfers interviewed, 184 injuries (35.2%) were reported within the 12 months before the study was conducted. In 2007, Fradkin, Windley, Myers, Sell, and Lephart studied 304 golfers injury patterns and 111 golf injuries (36.5%) were reported. Beside of retrospective studies, a prospective one-year survey studying golf injuries of 588 golfers at 7 Australian golf clubs was conducted by McHardy et al. in According to the result, 78 players reported 93 injuries during the one-year study, which an injury rate of 15.8% could be concluded. Common Anatomical Sites of Golf Injuries As a golf swing involves much of the muscles in our body, injuries would occur at every body region and parts. Among anatomical regions, the most common region to be injured was the upper extremities (McNicholas, Nielsen, and Knill-Jones, 1998; Palmer, Young, Fox, Lindsay, and Vandervoort, 2003),

21 10 which includes body parts such as shoulders, elbows, wrists and hands. Though most injuries were found at a golfer s upper extremities, if we look into the injury patterns according to specific injured body parts, the lower back was the most common injured body part found in golfers according to the previous studies conducted (Finch, Sherman, and James, 1998; Fradkin, Cameron, and Gabbe, 2005; McHardy, Pollard, and Luo, 2007; McHardy, Pollard, and Luo, 2007). And in the study of Batt in 1992, which classified the injuries into groups of actual injuries and incidental injuries, also found the back region was the most common incidental injury site to amateur golfers, and the second most common in actual injuries. In total, the region was also the most common injury site reported in the study. According to the study conducted by Van Der Steenhoven, Burdorf and Tromp-Klaren in 1994, 31.6% of the observed

22 11 golfers experienced back pain within the 12-month study period. With citations of the studies of Hosea, Gatt, Galli, Langrana and Zawadsky (1990) and Pink, Perry and Jobe (1993), the researchers concluded that golf activities would increase the probability of back pain occurrence to novice golfers because the golf swing included particular strenuous movements. Apart from lower back, shoulders and elbows were also very common to golfers. As presented by Kim, Millett, Warner, and Jobe (2004), shoulders were commonly affected with golf activities, especially the lead shoulder, which is the left shoulder of a right-handed golfer, vice versa. Golfers would be affected by shoulder problems such as acromioclavicular arthrosis, rotator cuff tear, and glenohumeral arthrosis. Stockard (2001) mentioned the findings of Kohn (1996) in his article, which stated that 24% of the amateur golfers

23 12 suffered from elbow problems. The problems included medial epicondylitis, or commonly referred as golfer s elbow. Golfers would get their dominant arm s elbow injured with golfer s elbow after repetitive swings, which led to excessive impact loading to the elbow joint. In the previous studies, relatively less injuries were related to lower extremities. Among the injuries in lower extremities, most of those were located at knees, ankles and feet. For example, knee sprain, ankle sprain, and plantar fasciitis. However, despite fewer injuries were recorded at lower extremities, the older golfers would have a greater chance in getting injuries at their lower body, which would be explained later. Types of Golf Injuries Strain was found to be the most common type among golf injuries. In the study conducted by Fradkin et al. (2005), 67.9% of the injuries reported were strains, followed by

24 13 tendinitis. In another study carried out by Fradkin et al. (2007), strain was also the most common type of injuries, with 37.8% of the overall injuries, followed by stiffness and inflamation. According to the study of Nicholas et al. (1998), nearly half (47.6%) of the respondents had been struck by a golf ball. And according to Finch et al. (1998), most of the golf injuries which required emergency department treatments were caused by being struck by golf balls. Similarly, Fradkin et al. (2006) found that 69.8% of the injuries presented to an emergency department were caused by being hit by golf balls or clubs or through a collision with others. These showed golfers were facing the risk of being hit by hard objects easily when playing golf, and usually caused serious injuries such as open wounds which required emergency unit treatment.

25 14 Causes and Aetiology of Golf Injuries According to the literatures reviewed, most of the incidents which caused golf injuries were chronic instead of acute incidents. According to the study of Gosheger et al. (2003), among the 637 reported injuries in the survey, 82.6% of the injuries were related to overuse problems, and only 17.4% were due to acute trauma events. According to the research findings, the two most common causes of golf injuries were overuse and incorrect swing mechanics. Overuse was found to be the main cause of injuries in studies carried out by Fradkin, Cameron, and Gabbe, both in 2005 and 2007; Improper swing mechanics was the second most common cause of injuries in the study of Fradkin et al. in 2005, but in other literatures, it was the prime cause in injuries. In the studies carried out by Batt (1992) and McHardy, Pollard, and Luo (2007), it ranked first in the causes of injuries, followed by overuse in both studies.

26 15 These proved that the two causes were the most common ones in causing a golfer s injuries during the game. Factors Influencing Golf Injury Patterns Age According to the findings of Fradkin et al. (2007), younger golfers were more likely to be injured when participating in golf activities. According to the researches which included assessment of injuries of different age groups, the younger golfers would be more prone to elbow and wrist injuries (Batt, 1992), pelvic and wrist injuries (Fradkin et al., 2005), and back injuries (Nicholas, Reidy, and Oleske, 1998). As for the common injured regions for older golfers, most of the findings from the researches were similar. They agreed that the aged golfers would suffer more from injuries of lower body or lower extremity. In the study in 2005, Fradkin et al. stated that older golfers would have a greater chance

27 16 in suffering from knee and ankle injuries than other age group golfers. And in the study conducted by Frankin et al. in 2007, it was found out that knee, groin and foot injuries were more common to the older golfers. The phenomenon that senior golfers would injure their lower extremities more was explained in the study of Fradkin et al. in In the study, Fradkin et al. suggested the reason of it as older golfers would easily fall on the golf course, causing injuries to lower body, such as knees, ankles, and feet. However, in a study conducted by Palmer, Young, Fox, Lindsay, and Vandervoort in 2003 found the results not similar to those mentioned findings. The researchers focused on investigating golf injury patterns of senior golfers who were at least 50 years old. Among the senior golfers investigated, half of them reported musculoskeletal conditions which affected their golf game in the past 12 months prior to the study. Besides, the researchers found that the golfers would be more likely to suffer from low back

28 17 pain. And the suggestion that most of their injuries happened at their upper extremities was also supported by Nicholas et al. (1998). And in the study of Batt (1992), it stated shoulder injuries would easily occur to older golfers, which also differs from other findings. Gender According to Batt (1992), the percentage of male injured golfers was 56%, while compared with that of female golfers (59%), the percentage of male golfers was just marginally lower. And in the researches conducted by Gosheger et al. (2003) and Fradkin et al. (2007), there were no significant differences in injury rate, severity and anatomical distribution between male and female golfers in both studies. Despite of these, in the study of Nicholas et al. (1998), women were more likely to have upper extremity problems after participating in golf activities, and male golfers would injure their back more. Furthermore, Fradkin, Cameron, and

29 18 Gabbe (2006) studied the injured cases that were within the period between April 1997 and December 2002, which required presentation to emergency unit in Victoria, Australia. Male patients outnumbered female patients by 3:1. Playing Level According to the study of Fradkin et al. (2007), less skilled golfers were less likely to get an injury than more skilled golfers. The researchers conclusion was explained as more skilled golfers would need more time engaged in golf activities; hence, the more exposure hours would lead to more injuries. Apart from difference in injury frequency, some researches stated there were differences in anatomical distribution of injuries in golfers with different playing levels. Batt (1992) stated that better golfers would be more likely to suffer from elbow and wrist injuries, while the less able golfers would get shoulder injuries more easily.

30 19 According to Fradkin et al. (2005), pelvic, wrist, thorax and forearm injuries would occur to a better golfer more often. And in the study conducted by Fradkin et al. in 2007, less skilled golfers would be more likely to injure their hip, elbow and knees. Also, Nicholas et al. (1998) indicated higher handicap players upper extremities would be at a greater risk of being injured than those of lower handicap ones. At the same time, there were researches which stated that no significant differences in injury patterns between high handicap and low handicap players were found in their studies (Gosheger et al., 2003; Fradkin et al., 2007). Warm-up Habits According to the findings of Gosheger et al. in 2003, the golfers who warmed up for at least 10 minutes would suffer fewer injuries than those who did not have adequate warm up exercises. And in the study of Fradkin et al. in 2007, it

31 20 showed that golfers without regular warm-up habits would be more likely to injure themselves. Studies had been done to investigate the warm-up patterns of amateur golfers. According to the studies conducted by Fradkin, Finch, and Sherman in 2001, only 54.3% of golfers performed some form of warm up activities. In the study of Fradkin, Windley, Myers, Sell, and Lephart in 2008, only 18.1% and 16.8% of golfers performed appropriate warm up before playing on course and practice respectively. The findings highlighted that golfers were not aware of the importance in warm up exercises before playing golf, and had inadequate knowledge in preventing golf injuries. Summary of Literature Review To summarize, most of the golf injuries appeared at a golfer s upper extremities, while the lower back was the most common injured body part. Most of the injuries were due to chronic reasons, such

32 21 as overuse and overpractice, instead of acute incidents. And strains dominated the type of golf injuries. As for the potential factors which affect the injury patterns of golfers, age, gender, and playing level could be affecting the patterns, and were proved to be influencing factors which caused differences in injury frequencies and injured anatomical sites among golfers with different demographic background. Besides, some studies found that adequate warm up could be an effective measure to prevent golf injuries.

33 22 CHAPTER 3 METHOD The method of this study will be illustrated in the following parts: i) Subjects; ii) Instrument; iii) Procedures; iv) Data Collection; and v) Data Analysis. Subjects The subjects were both male and female golfers amateur golfer in Hong Kong, aged 18 or above. The total number of subjects was 224. The subjects will be divided into groups according to their gender, handicap and age respectively when finding the correlation between the variables and golf injury occurrence. Subjects will be divided into five groups according to their age, including i) 18 to 30; ii) 31 to 40; iii) 41 to 50; iv) 51 to 60; and v) 61 and above. As for playing level, subjects will be categorized into five groups according to their handicap, including groups of i) scratch to 10; ii) 11 to 20; iii) 21 to 30; iv) 31 to 40; and v) No handicap.

34 23 Instrument As there was no previous studies data collection instrument available, a self-designed questionnaire was developed (see Appendix A). The development of questionnaire was based on the review of literature related to the topic. There consists of three parts of the questionnaire. In Part A, the background information of the interviewees, including participation rate, complementary fitness training programs, warm-up habits, and perceived injury knowledge were collected; In Part B, the golf injury information of interviewee was investigated, enquiring information about the injured body region and type of injury, causes of injury, treatments made, and needed recovery time; In Part C, demographic information was recorded, including gender, age, and handicap. Procedures A pilot test was conducted before the main study. 30 amateur golfers were invited to take part in the test. The

35 24 purposes of the pilot test were i) to check the appropriateness of vocabulary usage; ii) to test if the subjects would be able to understand and answer the questions; and iii) to see if there were any other problems regarding the questionnaire. In the main study, questionnaires were distributed and administered by an interviewer. The respondents were randomly selected. They were required to fill in the questionnaire and return it on the same occasion. Data Collection The questionnaire was distributed to golfers at the pier of The Jockey Club Kau Sai Chau Public Golf Course at Sai Kung. The participation of the study was voluntary and the information collected was handled confidentially and was destroyed after the research process. The data collection period was held from March 2012 to April 2012.

36 25 Data Analysis All of the data collected from respondents will be input into Predictive Analytics SoftWare Statistics (PASW Statistics ), and Microsoft Excel 2010 for further analysis. The level of significance of all the statistical testing performed was set at The injury pattern of the respondents will be shown in descriptive statistics such as frequencies and percentages, as well as personal information of respondents. Chi-square (x 2 ) will be used to find out whether there were significant differences in injury pattern of respondents, regarding different factors, including age, gender, and playing level. And Pearson Production Moment Coefficient of Correlation (r) will be used to determine if there were correlations between age, gender, playing level and golf injuries.

37 26 CHAPTER 4 ANALYSIS OF DATA The study was carried out to investigate the injury patterns of Hong Kong amateur golfers, and find out whether there were any relationships between injury occurrence pattern and demographic variables including age, gender, and playing level. As there were literatures supporting the fact that supplementary fitness training and warm-up patterns could help in preventing golf injuries, therefore the warm-up patterns and supplementary training frequency were also investigated. The relationship between the preventive measures and injury frequency was then examined in the study. The presentation of results of the study would be divided into the following parts: 1. Demographics of respondents

38 27 2. Exposure time in golf activities of respondents 3. Supplementary fitness training pattern 4. Warm-up patterns of respondents 5. Respondents injury patterns 6. Common injured anatomical positions to different demographic backgrounds 7. Types of golf injuries 8. Chi-square test results of injury pattern and variables 9. Correlation between age, gender, playing level and injury patterns 10. Causes of injuries 11. Treatments of golf injuries 12. Recovery time required 13. Respondents knowledge in preventing golf injuries

39 28 Results 1. Demographics of respondents In this study, subjects were randomly chosen to answer the questionnaire. Among the total of 224 respondents, 154 (72.8%) were male and 54 (27.2%) were female. Table 1. Gender Distribution of Respondents N % Male % Female % Total % The respondents were then divided into respectively groups according to their age and handicap, for further investigation of the correlation between age, playing level and injury patterns. As shown in Table 2, 11 (4.9%) respondents were in the group of 18 to 30 years of age, 52 (23.2%) were 31 to 40 years old, 91 (40.6%) respondents were in the group of 41 to 50 years old, 62 (27.7%) respondents

40 29 were 51 to 60 years old, and 8 (3.6%) respondents were older than 60 years of age. Table 2. Age Distribution of Respondents N % 18 to % 31 to % 41 to % 51 to % 61 or above 8 3.6% Total % As for the distribution in handicap, 14 (6.3%) respondents obtained a handicap index of 0 to 10, 49 (21.9%) respondents were 11 to 20 handicappers, over half (N = 117, 52.2%) of the respondents had a handicap of 21 to 30, 23 (10.3%) of the respondents had a handicap of 31 to 40, and 21 (9.4%) of the respondents had no handicap. Table 3. Handicap Distribution of Respondents N % 0 to % 11 to % 21 to % 31 to % No handicap % Total %

41 30 2. Exposure time in golf activities of respondents According to the responses of amateur golfers interviewed, most of the interviewed amateur golfers (N = 76, 33.9%) spent in average 4 to 6 hours each week in golfing activities, including hitting balls in driving ranges and playing rounds of golf on a golf course. 23.2% of them (N = 52) spent 1 to 3 hours. About 20 percent of the respondents (N = 45, 20.1%) played golf for more than 9 hours each week in average, and about 14 percent (N = 32) of the respondents spent an average of 7 to 9 hours each week. Less than 9 percent of the respondents (N = 19) spent not more than an hour in golf activities a week. Table 4. Exposure time in golf activities of respondents N % Less than 1 hour % 1 to 3 hours % 4 to 6 hours % 7 to 9 hours % More than 9 hours % Total %

42 31 3. Supplementary fitness training patterns Some literatures stated that supplementary fitness training such as weight training and stretching could help in preventing golf injuries, therefore the related training pattern of the respondents were recorded to see if there was a significant relationship between the training and injury occurrence in golf activities. About 80 percent of the respondents engaged in supplementary exercises. Most of the respondents (32.6%, N = 73) took less than an hour in average each week in supplementary training. 57 (25.4%) and 30 (13.4%) of the respondents spent 1 to 2 hours and 3 to 4 hours in the training respectively. 9.4% of the respondents engaged in more than 4 hours of supplementary training in average each week. About one-fifth (N = 43, 19.2%) of the respondents did not participate in any supplementary exercises.

43 32 Table 5. Hours in Supplementary training of respondents N % Never % Less than 1 hour % 1 to 2 hours % 3 to 4 hours % More than 4 hours % Total % 4. Warm-up patterns of respondents In the study, the warm-up pattern of the amateur golfers was also investigated to see whether it is an influencing factor to golf injuries. Among the golfers interviewed, over 90% (N = 202) of them did some kind of warm-up exercises before golf activities. Only not more than 10% (N = 22) of them did not have the habit of doing warm-up exercises. Table 6. Warm-up Frequency of Respondents N % Do warm-up % Do not warm-up % Total %

44 33 Among the players who would do warm-up exercises before golf activities, most of them did more than one kind of warm-up exercises. 81 (40.1%) and 62 (30.7%) of them did two kinds and three kinds of warm-up exercises respectively. 5 (2.5%) respondents did 4 different warm-up exercises before golf activities. Meanwhile, 26.7% (N = 54) of the respondents who did warm-up did only one kind of warm-up exercises. Table 7. Kinds of Warm-up Exercises Performed by Respondents N % One kind % Two kinds % Three kinds % Four kinds 5 2.5% Total % According to the responses from the golfers who did warm-up, over 40 percent (N = 182, 43.1%) of them stretched before playing golf. 144 (34.1%) of them did airswing and 87 (20.6%) of them chipped balls. 4 (0.9%)of the golfers jogged and 5 (1.0%) did other forms of warm-up exercises, including Tai-chi, brisk

45 34 walking and putting. Table 8. Types of Warm-up Performed by Respondents N % Airswing % Stretching % Jogging 4 0.9% Chipping of balls % Others 5 1.2% Total % Figure 1. Types of Warm-up Performed by Respondents 5. Respondents injury pattern 92 out of 224 respondents (41.1%) reported injuries in the 12 months. A total of 214 injuries were recorded. In average, each golfer sustained 2.33

46 35 injuries in a year. Nearly 60% of the injuries (N = 128) occurred in the upper extremities of a golfer. Over one-fifth (N = 47, 22.0%) of the injured respondents had their injuries at their trunk, and 18.2% of the injuries occurred in their lower extremities. Most of the injuries occurred in a golfer s lower back, with 42 injuries (19.6%) reported to be related to back region. The next common injury site was wrist and hand (N = 39, 18.2%), followed by elbow (N = 37, 17.3%) and shoulder (N = 30, 14.0%). Among the injuries reported, the most common injury was golf elbow (medial epicondylitis), which was suffered by 27 golfers (12.6%). Lower back strain was the second most common injury occurred, which had 22 (10.3%) records in the past 12 months. The following most common injuries were shoulder strain (N = 21,

47 36 9.8%), forearm strain (N = 20, 9.3%), wrist sprain (N = 19, 8.9%), lower back chronic/overuse pain (N = 17, 7.9%), wrist chronic/overuse pain (N = 16, 7.5%) and knee sprain (N = 15, 7.0%). The injury pattern was summarized in Table 9.

48 Table 9. Summary of Injury Patterns 37 N % Head contusion 2 0.9% Head total 2 0.9% Head total 2 0.9% Shoulder sprain 9 4.2% Shoulder muscle strain % Shoulder total % Elbow contusion % Golfers elbow (Medial epicondylitis) % Elbow total % Forearm muscle strain % Forearm total % Wrist sprain % Wrist chronic /overuse pain % Hand abrasion 4 1.9% Wrist and hand total % Upper extremities total % Lower back strain % Lower back vertebralsubluxation 3 1.4% Lower back chronic /overuse pain % Lower back total % Abdomen muscle strain 5 2.3% Abdomen total 5 2.3% Trunk total % Knee sprain % Knee meniscus tear 2 0.9% Knee chronic/overuse pain 1 0.5% Knee total % Ankle sprain 9 4.2% Ankle fracture 1 0.5% Plantar faciitis 3 1.4% Foot total % Quadriceps strain 3 1.4% Hamstring strain 2 0.9% Calf strain 2 0.9% Quadriceps contusion 1 0.5% Muscles total 8 3.7% Lower extremities total % Total 214

49 38 Figure 2. Frequencies of Injuries Suffered Figure 3. Frequencies of Injuries Suffered by Anatomical Body Parts

50 39 Figure 4. Percentages of Injuries suffered by Anatomical Regions 6. Common injured anatomical positions to different demographic backgrounds According to the data collected, differences in demographics would lead to differences in injured anatomical sites. As shown in Table 10, most male golfers tend to injure their lower back, where 30 injuries (20.1%) were related to lower back in the past 12 months for male golfers. Wrist and hand, and elbow were the following common injured sites, with 27 injuries (17.5%) each.

51 40 For female golfers, most of the injuries occurred at wrist and hand (N = 12, 20.0%). Lower back was the second most common injured site for them, where 11 injuries were recorded. It was closely followed by shoulder and elbow, with 10 cases (16.7%) each. Table 10. Gender Differences in Injury Patterns Gender Male Female Total N % N % N Head total 2 1.3% 0 0.0% 2 Shoulder total % % 30 Elbow total % % 37 Forearm total % % 20 Wrist and hand total % % 39 Lower back total % % 42 Abdomen total 2 1.3% 3 5.0% 5 Knee total % 3 5.0% 18 Foot total % 2 3.3% 13 Lower extremity muscles total 6 3.9% 2 3.3% 8 Total % % 214

52 41 Figure 5. Injuries Suffered by Different Gender Groups The groups in comparing injured sites for age were redefined in consideration of the little number of samples interviewed in groups 18 to 30 years old, and 61 years old or above. The summary was provided in Table 11. Young golfers tend to injured their wrist and hand most. In the groups of 18 to 40 years old and 41 to

53 42 50 years old, the region was in first place in injury frequency, which occupied 22.2% (N = 14) and 22.0% (N = 11) of the groups overall injuries respectively. Similarly, lower back was the second most common injured region for both groups as well, 19.0% (N = 12) and 20.0% (N = 10) of the injuries were related to the region. The two groups each had another site which was second most common. They were shoulder (N = 12, 19.0%) for the group of 18 to 40 years old, and elbow (N = 10, 20.0%) for the group of 41 to 50 years old. As for the older golfers, they tend to injured themselves with elbow injuries the most (N = 22, 21.8%), followed by lower back (N = 20, 19.8%) and wrist and hand (N = 14, 13.9%).

54 43 Table 11. Injury Pattern Across Different Age Groups Age 18 to to or above Total N % N % N % N Head total 0 0.0% 1 2.0% 1 1.0% 2 Shoulder total % % % 30 Elbow total 5 7.9% % % 37 Forearm total 4 6.3% % % 20 Wrist and hand total % % % 39 Lower back total % % % 42 Abdomen total 1 1.6% 2 4.0% 2 2.0% 5 Knee total % 1 2.0% 9 8.9% 18 Foot total 4 6.3% 4 8.0% 5 5.0% 13 Lower extremity muscles total 3 4.8% 0 0.0% 5 5.0% 8 Total % % % 214 Figure 6. Injuries Suffered by Different Age Groups

55 44 In the investigation of differences in injury frequencies between golfers with different playing levels, the golfers were divided into two main groups, the lower handicappers (0 to 20), and the higher handicappers (21 to 40). The injury information of golfers without a handicap would not be compared. According to the Table 12, the players with lower handicap would injure their lower back most when engaging in golf activities (N = 23, 25.0%). Wrist and hand were also common to the higher achievers, with 18.5% (N = 17) of the injuries in the group were related to the body part. Meanwhile, not few injuries were related to elbow and shoulder, which occupied 14.1% (N = 13) and 13.0% (N = 12) of the injuries of the group respectively. As for the higher handicappers, about one-fifth (N = 21, 19.8%) of the group s injuries occurred at the golfer s elbow. 17.9% (N = 19) of the injuries were

56 45 related to wrist and hand. Both shoulder and lower back were the following common injured sites, with 14.2% (N = 15) each. Table 12. Injury Information for Different Handicap Groups Handicap 0 to to 40 No handicap Total N % N % N % N Head total 2 2.2% 0 0.0% 0 0.0% 2 Shoulder total % % % 30 Elbow total % % % 37 Forearm total 8 8.7% % 0 0.0% 20 Wrist and hand total % % % 39 Lower back total % % % 42 Abdomen total 3 3.3% 2 1.9% 0 0.0% 5 Knee total 6 6.5% % 1 6.3% 18 Foot total 6 6.5% 6 5.7% 1 6.3% 13 Lower extremity muscles total 2 2.2% 5 4.7% 1 6.3% 8 Total % % % 214

57 46 Figure 7. Injuries Suffered by Different Handicap Groups 7. Types of golf injuries According to Table 13, the types of injuries were displayed. Over one-third of the injuries (N = 75, 35.0%) were strains. Followed by chronic/overuse injuries (N = 64, 29.9%) and sprain (N = 52, 24.3%). Other injuries only occupied a fewer proportion of injuries.

58 47 Table 13. Types of Golf Injuries N % Strain % Chronic/overuse % Sprain % Contusion % Abrasion 4 1.9% Ligament/tendon rupture 2 0.9% Fracture 1 0.5% Others 3 1.4% Total % Figure 8. Types of Golf Injuries

59 48 8. Chi-square test results of injury pattern and variables Chi-square test was conducted to find out if there were significant differences in injury patterns between golfers of different age groups, gender, and handicap. The data were presented in Table 14. Significant differences were found among age groups (p = 0.019) and participation hours (p = 0.038). Meanwhile, the differences found in other variables, including gender (p = 0.369), handicap (p = 0.311), warm up pattern (p = 0.636), and supplementary fitness training (p = 0.574) were found insignificant.

60 49 Table 14. Chi square Test for Differences between Variables and Injury Frequency No. of Categories N injured respondents Chi square p Gender Male Female Age group 18 to to to to or above 8 5 Handicap 0 to to to to No handicap* 20 7 Less than 1 hour Participation hours 1 to 3 hours to 6 hours to 9 hours More than 9 hours Warm up Had None 22 8 Supplementary Had fitness training None *did not include in the chi square calculation

61 50 9. Correlation between age, gender, playing level and injury patterns Pearson Production Moment Coefficient of Correlation (r) was used to analyze the degree of correlation between various variables and injury pattern of amateur golfers. According to the output from PASW Statistics 18, which was shown in Table 15, with the consideration of 0.05 significance level, only participation hours (r = , p = 0.021) was a significant factor which affects the number of injuries of an amateur golfer. The correlation was a negative correlation as Pearson Correlation value was negative. Other tested factors, including gender (r = , p = 0.371), age group (r = , p = 0.169), handicap (r = 0.116, p = 0.100), warm-up (r = 0.032, p = 0.638), and supplementary fitness trainings (r = , p =

62 ) were not correlated with injury occurrence frequency. Table 15. Pearson Correlation between Variables and Injury Frequency No. of Categories N Pearson Sig injured Correlation (2-tailed) respondents Gender Male Female Age group 18 to to to to or above 8 5 Handicap 0 to to to to No handicap* 20 7 Less than 1 Participation hours hour to 3 hours to 6 hours to 9 hours More than 9 hours Warm up Had None 22 8 Supplementary Had fitness training None *did not include in the correlation calculation

63 Causes and aetiology of injuries According to the responses, as displayed in Table 16, most of them interpreted that their injuries were due intrinsic factors. Overuse of a specific body part (N = 57, 24.3%) was the most significant factor in causing golf injuries. The next was incorrect swing mechanics (N = 52, 22.1%). 45 (19.1%) of the injured respondents blamed that their injuries were due to inadequate warm-up. 29 (12.3%) and 27 (11.5%) of them mentioned that tiredness and poor body condition were the causes of their injuries respectively. Extrinsic factors, including venue (N = 5, 2.1%), others negligence (N = 7, 3.0%) and improper equipment (N = 11, 4.7%) only made up little cases of the injuries reported. And 2 golfers (0.9%) reported other factors which caused their injuries, such as changes in weather.

64 53 Table 16. Causes and Aetiology of Golf Injuries N % Intrinsic factors Not enough warm-up % Poor body condition % Overuse of a specific body part % Tiredness % Inappropriate swing techniques % Extrinsic factors Venue 5 1.8% Others negligence 7 2.7% Improper equipment % Others 2 0.9% Total % Figure 9. Causes and Aetiology of Golf Injuries

65 Treatments of golf injuries After the golfers were injured, most of the respondents (N = 61, 47.3%) injuries were insignificant that only requires rest to recover. 37 (28.7%) of them seek medical consultation at physiotherapy. 25 (19.4%) of them treated their injuries with Chinese bone-setters ( 中醫跌打 ). 3 (2.3%) respondents required emergency treatments. And 3 others (2.3%) treated their injuries with other rehabilitation methods, such as massage, acupuncture, and pain-killers. Table 17. Treatments of Golf Injuries N % Rest % Emergency Unit 3 2.3% Physiotherapy % Chinese Bone-setting % Others 3 2.3% Total %

66 55 Figure 10. Treatments of Golf Injuires 12. Recovery time required Among the 92 respondents who were injured, about one-third of them (N = 31, 33.7%) required 1 to 2 weeks to recover from the injury. 21.7% (N = 20) of them needed 3 to 4 weeks and 27.2% (N = 25) of them needed over a month of recovery time. Only 17.4% (N = 16) of the injured persons could return to play within a week.

67 56 Table 18. Recovery Time Required N % Less than a week % 1 to 2 weeks % 3 to 4 weeks % Over 4 weeks % Total % Figure 11. Recovery Time Required 13. Respondents knowledge in preventing golf injuries The questionnaire interviewed the respondents whether they believe they had acquired sufficient knowledge in preventing golf injuries. The vast majority of the respondents (N = 122, 54.5%) believed

68 57 that they had not enough knowledge in preventing injuries. 45.5% of them (N = 102) thought they had enough knowledge in the related field. Table 19. Respondents Belief in Own Injury Prevention Knowledge N % Enough % Not enough % Total % As for methods of preventing golf injuries, most of the respondents (N = 190, 36.5%) believed stretching was helpful in injury prevention. 34.2% of them (N = 178) trusted warm-up exercises would minimize the occurrence of injuries, and 18.1% of them thought that golf professionals instruction could help. Other measures, including weight training and club fitting, were supported by 6.7% (N = 35) and 4.4% (N = 23) respectively.

69 58 Table 20. Preventive Measures Supported by Golfers N % Warm-up % Weight training % Stretching % Club fitting % Golf Pro instruction % Total % Figure 12. Preventive Measures Supported by Golfers

70 59 Discussions A total of 224 Hong Kong amateur golfers participated in this study. The respondents participation levels, warm up patterns, supplementary fitness training participation, knowledge in preventing golf injuries, and injury records in the past 12 months were investigated to study if there were correlations between various factors and injury occurrence, hence, specific preventive measures could be implemented in the future to prevent golf injuries. Frequency of golf injuries In the study, it was found that golf injuries occurred to 41.1% of the studied population. When comparing with similar previous studies, the incidence rate was slightly higher than that in studies conducted by Fradkin et al. (2005), Gosheger et al. (2003) and Fradkin et al. (2007), which the incidence rates were 35.2%, 39.7%, and 36.5% respectively. However, the incidence rate of this study was lower than that

71 60 in the study conducted by Batt in 1992, which reported that 57% of the respondents were injured throughout golf activities. Among all the injuries, golf elbow (medial epicondylitis) was the most common injury. It was followed by back strain, shoulder muscle strain and forearm strain. Anatomical sites of golf injuries As a golf swing involves much of the muscle groups in our body, and golfers are prone to different hazards on a golf course, they are likely to be injured at every anatomical site with different kinds of injuries. Most of the injuries reported by the respondents were related to upper extremity, followed by trunk, and lower extremity. When looking deeper into the injury statistics, lower back was the most common injured anatomical position, followed by wrist and hand, elbow, and shoulder. The result

72 61 corresponds with the study conducted by Finch et al. (1998), which study concluded that the most common injured body regions for injuries treated at sports medicine clinics were lumbar spine/lower back, followed by elbow and knee. These findings also agreed the hypotheses of this study which was made before at start of the study. Causes of golf injuries Respondents indicated that most of the causes of injuries were intrinsic, which could be controlled by the golfers themselves. According to the golfers perception, a vast majority of their injuries were caused by overuse of a particular body region, for example injuries like golf elbow, chronic or overuse pain of wrist, knee, and lower back. The next most common cause of injuries was improper swing technique. Without enough warm-up was also a common factor which caused injuries.

73 62 Aetiology of golf injuries Most of the injuries recorded were strains, such as shoulder muscle strain, forearm strain, and lower back strain. This would because of the quick motion of a golf swing which caused tension to muscles involved. With the causes such as inadequate warm up, tiredness, or poor body condition, golfers would strain their muscles very often. Chronic injuries were also common to golfers because of the repetitive golf swing. During golf activities, golfers would have to repeat their golf swing for many times. For example, a golfer would need to swing at least 40 to 50 times in a round of golf, the higher the handicap, the more swings the golfer needed to finish a round. Besides, the number of swings would be double and even triple when the golfer was practicing in a driving range. The high number of swings with full power would lead to chronic injuries to tendons or ligaments, such as golf elbow, and other region s tendonitis.