An Epidemiologic Survey of injury in Golfers

Transcription

1 Journal of Sport Rehabilitation, 1998, 7, O 1998 Human Kinetics Publishers, Inc. An Epidemiologic Survey of injury in Golfers John J. Nicholas, Margaret Reidy, and Denise M. Oleske In order to supplement the literature that describes individual injuries of the shoulder, carpal tunnel, and back in golfers, we administered a survey to demonstrate the incidence of golfers' injuries and describe the most frequent types. A questionnaire was administered to 1,790 members of the New York State Golf Association (amateur) under age 21. Three hundred sixty-eight players responded. Half of those responding had been struck by a golf ball at least on one occasion (47.6%), and 23% of the injuries were to the head or neck. Male golfers were 2.66 times more likely to be struck by a golf ball than females. Women and golfers with a higher handicap were at an increased risk for upper extremity problems, whereas younger and overweight golfers were more likely to have golf-related back problems. We concluded that golf is associated with a significant morbidity. Repetitious trunk and upper limb motions probably contribute to musculoskeletal disorders. However, an unexpectedly high incidence of trauma from projectile golf balls leads to the conclusion that no amount of stretching or muscular exercise is as important as increased alertness by golfers to decrease this hazard. Golf, an activity that appeared early in the world of sport, is reported to have originated in Scotland and is not considered a contact sport, although a decrease in vertebral height and an increase in \io,max are reported to occur from simulated play (14). Personal involvement with this sport led us to investigate the extent and type of injuries associated with golf. The available literature is not extensive, but it suggests that various musculoskeletal injuries to tendons and bony or cartilaginous structures are the most common, and that conditioning in the off-season is important to prevent these injuries (1, 6, 8). Therefore, we surveyed members of John J. Nicholas is with the Department of Physical Medicine and Rehabilitation, Rush Medical College, Rush Medical Center, 1653 W. Congress Parkway, Chicago, IL Margaret Reidy is with the Physical Medicine Department, Passavant Hospital, and the Department of Orthopedics, Division of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA. Denise M. Oleske is with the Department of Health Systems Management, Rush University.

2 Injury in Golfers 113 the New York State Golf Association (NYSGA) (amateur) to determine the nature and frequency of injuries to these golfers. Methods In May 1991 we developed a questionnaire that was mailed to the 1,790 members of the New York State Golf Association (amateur). The questionnaire consisted of 86 items covering demographic characteristics, health conditions, health habits, aspects of the golfer's game, specific injuries known to be related to golf, and treatment of these injuries. In this paper we report the analysis of only those items that pertained to acute or repetitive injury or that were thought to be associated with golfing or their treatment. We report the 368 responses to this study from individuals at least 21 years of age who had played golf for at least 1 year. Data were analyzed using the SPSS/PC+ computer program. Two-tailed bivariate tests were performed with chi square tests or t tests as appropriate. Multivariate logistic regression was used to evaluate a player's likelihood of being struck by a golf ball (yes = Vno = 0) and the presence or absence of musculoskeletal disorders (present = Vabsent = 0) in consideration of independent variables of interest. The independent variables, handicap, holes per week, weeks per year, years played golf, and age were included as continuous variables, whereas gender, smoking status, daily alcohol consumption, and handedness were treated as binary variables. The odds ratios (OR) were computed from the antilog of the beta coefficients from the multiple logistic regression equation. The 95% contidence intervals (CI) of the OR reported herein were computed as follows: erb" '"' I.%(" "'"'1. Descriptive Findings Results Of the 368 respondents, 79.8% were males, and the mean age of the group was 49.1 years (Table 1). The prevalence of smoking reported was very low (14.7%). A large proportion of the subjects reported having visited a doctor in the last year (57.3%). Nearly half of the respondents (44.6%) considered themselves overweight, and 38.9% reported consuming alcohol daily. The mean golf handicap was 8.5 (+6.8), indicating the high golf skill level of this group. (A lower handicap denotes greater skill, with professionals having a zero handicap.) The mean number of holes of golf played per week was 57.1 (f 22.0). The low prevalence of diabetes, hypertension, heart disease, emphysema, and cancer (Table 2) indicates that the sample was in general good health relative to the general population (10). Nonspecific arthritis was the most common health problem (17.9%), followed by tendinitis of the arm (16%), bursitis of the arm (14.7%), back conditions (14.1%), and golfer's elbow (10.3%) (Table 2).

3 114 Nicholas, Reidy, and Oleske Table 1 Sample Characteristics of Respondents to New York State Golf Association Survey (N = 368) Characteristic Value Mean age in years (SD) % Male % Smokers % Perceived self as overweight % Daily alcohol consumption % Visited physician at least oncelyear Mean golf experience in years (SD) Mean golf handicap (SD) Mean holes of golflweek (SD) Table 2 Reported Prevalence of Health Conditions of New York State Golf Association Members Health condition Percentage reporting Diabetes Hypertension Heart disease Emphysema Arthritis Cancer Golfer's elbow Carpal tunnel syndrome UInar nerve compression Tendinitis in arm Tendinitis in leg Bursitis in arm Bursitis in leg Back condition from golf A remarkable 47.6% reported having being struck, at least once, by a golf ball (Table 3). The legs were the most common site (37.9%), but 23.0% reported having been struck in the head or neck. The vast majority of these injuries were considered contusions. However, 2.5% of subjects reported having a concussion

4 Injury in Golfers 115 and 2.3% reported fractures of the nose, jaw, wrist, or knee from being struck. Of other injuries experienced, the majority were due to slipping on or near the tee (19.8%). The cumulative incidence of ever being struck by a golf ball is displayed in Table 4. An inverse relation between the cumulative incidence and age was observed, with younger players having a higher incidence. Males were 2.66 times more likely than females to have ever been struck by a golf c.001). Table 3 Characteristics of Reported Golf Injuries (N = 368) Characteristic Percentage reporting Ever struck by a golf ball Area ever struck by a golf ball Head Neck Trunk Upper extremity Lower extremity Most serious injury from striking golf ball Concussion Contusion CutAaceration Fracture Scratchlabrasion Strainfsprain Ever experienced other injuries related to golf Table 4 Cumulative Incidence of Being Struck by a Golf Ball, According to Age Group and Gender Cumulative incidence Age group: < Missing Gender: Male Female Overall

5 116 Nicholas, Reidy, and Oleske Bivariate Analyses of Risk Factors We next performed bivariate analysis of potential risk factors that we hypothesized might be associated with the golfer's health condition. Being male (OR = 3.39, 95% CI: , p =.02) and self-perception of being overweight (OR = 2.23, 95% CI: , p =.008) were found to be associated with golf-related back disorders. Persons with back disorders were also significantly younger than those without (mean age in years: 43.7 vs. 49.7,~ <.01). Smoking, daily alcohol intake, mean handicap, mean holestweek, mean weeks golftyear, and mean years playing golf were not significantly related to golf-back disorders. In contrast, females were more likely to have upper extremity disorders: golfers' elbow, carpal tunnel, ulnar nerve compression, tendinitis or bursitis in the arm (OR = 2.04, 95% CI: , p <.01). Persons with upper extremity disorders were also older (mean age in years: 54.6 vs. 46.7, p <. 01) and were worse players (mean handicap: injured 10.2 vs. not injured 7.8, p <.01). No other factors were found to be significant. Multivariate Analysis When gender, handicap, and age were simultaneously considered, only increasing age emerged as a risk factor for upper extremity problems (OR = 1.05, 95% CI: , p <.001). When we examined the likelihood of a golfrelated back problem, when all the significant findings from bivariate analyses were included, only younger age (OR = 0.96, 95% CI: , p =.007) and the perception of being overweight (OR = 2.75, 95% CI: , p <. 01) were found to be risk factors. Physician Contact and Satisfaction Last, we examined the type of health care provider sought to treat golf-related health problems and the degree of satisfaction with treatment related to golf injuries. The most frequently used providers for golf-related health problems were chiropractors, with 29.6% of the sample reporting having contacted a chiropractor for a golf-related injury or pain (Table 5). General practitioners (I l.l%), sports medicine orthopedists (10.6%), physiatrists (7.1%), and general orthopedists (9.8%) were the next health care providers most frequently seen. Satisfaction with care was 83.3% for chiropractors, 88.9% for sports medicine orthopedists, 81.3% for family practitioners, 86% for general orthopedists, and 92% for physiatrists. Despite the high level of satisfaction, 20.5% of the subjects felt that the doctors did not understand the relation of golf to their health problem or injury. Discussion This study is the first report of the magnitude of injury resulting from being struck by a golf ball. Nearly half of our subjects had been struck. This is in contrast to a

6 Injury in Golfers Table 5 wpe of Health Care Provider Contacted for Golf-Related Health Problem and Satisfaction With Treatment Provider % Contacted for golf-related problem % Satisfied Chiropractor Internist Osteopath General practitioner Family practitioner General orthopedist Sports medicine orthopedist Sports medicine specialist Rheumatologist Neurologist Neurosurgeon General surgeon Physical medicine and rehabilitation specialist study in the UK where only 3.1 % of the subjects reported ever being struck by a ball (1). At face value, this may seem contrary to logic, since our subjects as a group were skilled players (mean handicap: NY golfers, 8.5; UK club, 14.2). A possible explanation is that the American golfers hit the ball with greater force and hence the ball could find its way faster to an unsuspecting player, who might not hear the traditional "fore" warning because of the distance. Regardless of the reason, being struck by a golf ball can be particularly serious, especially considering that nearly a fourth of the injuries caused by a striking ball were to the head or neck. It may also be that our respondents so frequently described being struck by a golf ball because previous surveys did not inquire into this type of injury. Males may have a higher cumulative incidence of being struck by a golf ball because of more time spent on the golf course. Also, private courses may be less crowded at times when women play. With respect to musculoskeletal problems, 40.5% of our sample reported musculoskeletal problems attributable to golf. Upper extremity disorders were significantly related to increased handicap. This may suggest that upper extremity problems could be related to the cumulative trauma of swinging with inappropriate body mechanics. In future studies, the number of swings per day (course and practice range) could be queried to shed some light on this finding. In this study, the only risk factors found for golf-related back problems were younger age and the perception of being overweight. Increased body weight may

7 118 Nicholas, Reidy, and Oleske contribute to increased torque or shearing forces on the spine when the player swings or carries golf clubs. Younger players may follow through with greater torque than older ones. Mundt studied golf-related back problems utilizing multivariate techniques and did not identify golf as a risk factor for herniated lumbar or cervical discs (9). There are several limitations to our study. The response rate was low because the survey was anonymous and nonrespondents could not be followed up. However, according to the executive director of the New York State Golf Association (amateur), the age-gender composition of the study sample was similar to that of the general adult membership. We were not able to validate the respondents' reported medical conditions. Since nearly 60% had seen a physician in the past year and since self-reports of chronic conditions are typically over 90% valid, the reported medical conditions are likely to be accurate. Because of the low participation, however, the prevalence and incidence may not be accurate. If healthier persons and persons who are less likely to be struck by a golf ball did not respond to our survey, the rate of players struck by a golf ball is likely to be lower than we reported. Golf injuries have long been recognized and are the subject of recent reviews (6, 8) that stress the occurrence of musculoskeletal injuries and describe specific stretching, strengthening, and conditioning activities to prevent such injuries. McCarroll detailed the appropriate physical form that should be followed to prevent injury and recommended a Nautilus@ strengthening program(8). He and others have reported that the most common golf injuries are backaches, sprained wrists, and aching shoulders, and the most common sites of pain are the left wrist, the low back, the left hand, the left shoulder, and the left knee in right-handed golfers. He noted reports of fractured carpal bones, ulnar and medial nerve neuropathies, and an exploding golf ball with a liquid center that pierced the eye of a golfer. He also cited cases of a golfer who fractured his tibia by striking himself with a golf club, a golfer who was knocked unconscious by his partner's club, and a golfer who threw her putter in anger and stumbled over it, fracturing both wrists. He pointed out that death had occurred to golfers due to heat stroke, myocardial infarction, and striking power lines. Another golfer was indicted for the attempted murder of a golfer who "played through" his foursome. Another golfer reportedly killed his caddie with a club after missing a shot. Many other golf injuries have been described. Schultz and Leonard reported a case of 32-year-old recreational golfer who sustained an injury to her long thoracic nerve while driving a golf ball (12). They suggested that traction during the follow-through swing caused this injury. Isaacs and Schreiber presented the case of a 36-year-old recreational golfer who on arthroscopy was found to have avulsed the cartilage from the posterior aspect of his patella while driving a golf ball (5). This avulsion apparently fractured the cartilage of a lateral femoral condyle. Gillies and Gray reported on a 30-year-old professional golfer who sustained a comminuted stress fracture of his left tibia while swinging the golf club (4).

8 Injury in Golfers 119 Bystanders reported hearing the crack of the club hitting the ball followed by the crack of the tibia fracturing. Ekin and Sinaki reported three cases of vertebral compression fractures sustained during the rnidswing of golf (3). These occurred in 3 postmenopausal women, two of whom quit playing golf. Unlike our study, however, many authors have reported head injuries in golfers, due to being struck not with a golf ball but rather with a golf club. Lindsay, McLatchie, and Jenneff reported on 1,900 individuals with head injuries admitted to the neurosurgical unit of the Institute of Neurological Sciences in Glasgow, Scotland, between January 1974 and December 1978 (7). Golf-related injuries totaled 14 (27% of all sports-related injuries) and were the most frequently cited sport in the 52 sports-related head injuries group (horseback riding injuries being in second place). Thirteen golfers sustained skull fractures, 1 with an intracerebral hematoma and 2 with intracerebral contusions. All golfers were under the age of 16; 13 injuries were caused by a golf club and only 1 by a golf ball. The authors suggested "that youngsters should be forewarned of the need to stand well clear when others are wielding golf clubs." Brennan, from the Children's Hospital, Sheffield, UK, commented upon Prince William being struck on the head by a friend's golf club and sustaining a depressed skull fracture (2). The author recorded three cases from that institution and said that "hit by golf club" had been added to the criteria for skull x-rays in the head injury protocol. Smith et al. reported 11 cases of children, ages 6 to 14, who had severe head injuries from being hit with a golf club while golfing during a 12-month period (13). All were boys with a mean age of years. There were nine fractures. Nine subjects were hit on the backswing, and 2 were hit by golf balls. Only one accident occurred on a golf course, and no adult was present at any of the accidents. The severity and frequency of these head injuries have been duly noted; Parkinson reported that an item had been placed in the Rule Book of the Royal and Ancient Golf Club of St. Andrew's, as well as the United States Golf Association Rule Book, requesting that golfers look around to see that colleagues are clear before beginning practice or serious golf swings (11). It seems that children in England are more likely to sustain a head injury from a golf club while playing golf, but that golfers in the United States, especially those with a lower handicap, are more likely to be injured by a golf ball. Given the significance of injuries in our sample and the widespread popularity of golf, further inquiry is warranted. A longitudinal study would help confm the risk of injuries and determine more precisely the nature of risk factors. Most previous authors have emphasized stretching and muscle strengthening to prevent golf injuries and prepare for better golfing. Our study did not reveal any information that supports or disputes the benefit of these recommendations. However, most previous authors, when stressing rehabilitation from golf injuries or prevention of future golf injuries, neglect to point out that many injuries are

9 120 Nicholas, Reidy, and Oleske secondary to being struck by a golf ball while playing or practicing or even being struck by a club. Sports physicians, golf professionals, and health professionals must therefore take the lead in urging golfers to be more perspicacious and to look around them, both while playing and before addressing the ball. We conclude that musculoskeletal injuries occur frequently to golfers, and we urge physicians to treat them accurately and vigorously. The suggested strengthening and stretching conditioning activities are probably well worth following. We also urge golfers to be more attentive. In Great Britain, young golfers should be sure all are clear of their swing. In the U.S., perhaps golf courses should place signs on the tee that read, "Keep your eyes on the other golfer's ball also." References 1. Batt, M.E. A survey of golf injuries in amateur golfers. B,: J. Sports Med. 26:63-65, Brennan, P.O. Golf related head injuries in children. Brit. J. Med. 303:54, Ekin, J.A., and M. Sinaki. Vertabral compression fractures sustained during golfing: Report of three cases. Mayo Clin. Proc , Gillies, R., and I.C.M. Gray. Comminuted tibia1 fracture: An unusual stress fracture. Injury 23: , Isaacs, C.L., and F.C. Schreiber. Patellar osteochondral fracture: The unforeseen hazard of golf. Am. J. Sports Med. 20: , Jobe, F.W., and D.M. Schwab. Golf for the mature athlete. Clin. Sports Med. 10: , Lindsay, K.W., G. McLatchie, and B. Jennett. Serious head injury in sport. B,: Med. J. 281: , McCarroll, J.W. Golf. In Sports Injuries: Mechanisms, Prevention, and Treatment, R.C. Schneider, J.C. Kennedy, M.L. Plant, P.J. Fowler, J.T. Hoff, and L.S. Matthews (Eds.). Baltimore: Williams & Wilkins, 1985, pp Mundt, D.J., H. Pastides, A.T. Berg, J. SMar, and T. Hosea. An epidemiologic study of sports and weightlifting as possible risk factors for herniated lumbar and cervical discs. The Northeast Collaborative Group on Low Back Pain. Am. J. Sports Med. 21: , National Center for Health Statistics (NCHS). Current Estimates from the National Health Interview Survey, 1991, Series 10, No Hyattsville, MD: NCHS, Parkinson, D. Head injuries in golf: Think first. J. Neurosurg. 77: , Schultz, J.S., and J.A. Leonard. Long thoracic neuropathy for athletic activity. Arch. Phys. Med. Rehabil. 73:87-90, Smith, R.A., S. Ling, and L.W. Alexander. Golf-related head injuries in children. B,: Med. J. 302: , Wallace, P., and T. Reilly. Spinal and metabolic loading during simulation of golf play. J. Sports Sci. 11: , 1993.

10 Injury in Golfers 121 Appendix: Selected Questions From the New York State Golfer's Association Survey Do you have any of the following? (list of diseases) Do you consider yourself overweight? Do you smoke cigarettes? Do you drink alcoholic beverages? Do you regularly take any medication? How often do you see a physician? Have you ever injured your back seriously enough to alter your lifestyle? Have you ever seen a doctor for back pain or injury? Have you ever had back surgery? Have you ever taken medication for back pain? Have you ever had physical therapy for back pain? Have you ever been told to lose weight for back pain? Do you or your doctor believe golf has affected your back? Do you or your doctor believe your job has affected your back? Have you ever had any of the following diagnosed by a physician? (list of overuse syndromes) Do you or your doctor believe golf has affected any of the above conditions? Have you ever been shvck by a golf ball? If so, please explain the nature and seriousness of any such injury. Have you ever sustained any other injuries related to your golf game? Handicap: How many holes do you play per week? How many weeks of the year do you play? How many years have you played golf? If you have ever had back pain, did you miss time from golf due to back pain? Have you adjusted any part of your game to accommodate back pain or injury? If you have ever been treated by a doctor for pain or any injury related to your golf game or which affected your golf game, which type of doctor did you see? Did you feel your doctor adequately understood the relationship between your complaint and your golf game? Were you satisfied with your treatment? Acknowledgments We thank Edward D. Reidy, M.D., Intern, Sisters of Charity Hospital, Buffalo, New York; and Thomas E. Reidy, Sr., Executive Director, New York State Golf Association.