When Golf Hurts: Musculoskeletal Problems Common to Golfers L. Tyler Wadsworth, MD Corresponding author L. Tyler Wadsworth, MD Illini Sports Medicine, 301 West Lincoln Street, Suite 210, Belleville, IL 62220, USA. E-mail: lwadswor@slu.edu Current Sports Medicine Reports 2007, 6:362-365 Current Medicine Group LLC ISSN 1537-890x Copyright 2007 by Current Medicine Croup LLC Golfers most frequently report injuries to the low back, nondominant shoulder, and elbow. Injury patterns differ between elite and recreational golfers; professional and elite golfers tend to experience golf injury related to overuse while amateur golfers may experience injury related to adverse swing technique and overuse. Therapeutic interventions should include assessment and treatment of deficiencies in the kinetic chain and professional instruction to modify swing technique. Changes in the swing may include instruction in a more efficient technique or shortening the swing to decrease biomechanical forces affecting the injured area. Introduction Golf is a sport that can be played at all ages. According to the National Golf Foundation, there are over 26 million golfers in the United States and an estimated 50 to 60 million golfers worldwide [1]. The game continues to grow in popularity, measured by new courses built, rounds played, and number of participants. Unlike most sports, the skill and level of play of a golfer may increase through the fifth and even sixth decades of life. The wisdom, experience, and judgment of the experienced golfer can overcome the declining physical skills that accompany aging. Golf provides an important social and physical outlet for seniors, and is an acceptable fitness activity for players who walk the course [2]. A golfer walking the course while carrying his or her clubs expends roughly the same number of calories as walking 3.5 to 4 mph continuously on level ground [3]. Golf is an asymmetrical sport. Demands on the right and left side of the golfer's body differ. Rather than facing the line of play, in golf, one stands perpendicular to the line of play; therefore, there are differences in firing patterns of the shoulder muscles from right to left. In discussing the biomechanics and physics of the golf swing. references to dominant versus nondominant refer to the side the golfer is playing from right-handed versus lefthanded rather than right versus left brain dominance. The right-handed golfer stands perpendicular to the intended line of fiight with the left shoulder closer to the target. The swing is generally broken down into several phases: address, takeaway, backswing, downswing, acceleration, and follow-through. A basic understanding of the golf swing can assist in determining the site of injury associated with the golf swing. Differences in injury rates and patterns exist between professional and amateur golfers [4]. These differences appear to be related to differences in swing mechanics and time spent practicing and playing golf. Amateur golfers most frequently report injuries to the lower back and elbow. Conflicting data suggest variable rates of injuries to the hand and wrist, shoulder, and lower extremity [5,6]. Professional golfers report similar rates of nondominant wrist and lower back injuries to those of amateurs, but experience fewer elbow injuries. Female professional golfers experience more injuries to the left wrist as compared with male professionals, whereas male professional golfers experience more injuries to the left shoulder than their female counterparts [7]. Lateral epicondyle injuries are up to five times more common than medial epicondyle injuries in amateurs, but lateral and medial injuries occur with similar frequency among professional golfers. Other surveys have also addressed risk factors for golf injuries [5,8]. Overuse, poor swing technique, age, and lack of physical conditioning have been associated with golf injuries. Gosheger et al. [8] linked carrying one's own bag to injuries of the lower back, shoulder, and ankle. In a recent prospective survey of 588 amateur Australian golfers, McHardy et al. [6] associated injury with amount of play and "the last time clubs were changed." Low Back Pain Back injuries in the golfer include musculotendinous injuries (acute and chronic muscular strain, muscular spasm), acute disk injury, and exacerbation of the myriad causes of back pain unrelated to golf. Gountless hours on the driving range allow most professional golfers to hone and maintain smooth, efficient swings but are also a risk factor associated with overuse injuries. Professional golfers have the highest incidence of back injury of all professional athletes [9].
Musculoskeletal Problems in Golfers Wadsworth 363 Unlike professional golfers, low back pain in the amateur is frequently associated with poor swing techniques. Many golfers are sedentary and have poor strength, endurance, and flexibility. The inefficient and sometimes violent swinging of a golf club may result in acute or repetitive trauma to these weak, tight structures. This tendency is magnified by the "weekend golfer's" attempts to hit prodigious drives. Unfortunately, these attempts usually involve brute force rather than a well-coordinated, athletic movement, and can also cause injury. Amateur golfers generate 80% greater torque and shear loads than professional golfers during the golf swing [10]. This is likely related to the muscular and biomechanical inefficiency of the swings of amateur golfers as compared with their professional counterparts. Gombined torsion, compression, and lateral bending have been implicated in disk herniation [11]. Repeated, near-maximal exertion coupled with excessive biomechanical forces involved in the golf swing may cause injury to the spine of the weekend golfer. The range of injuries to the golfer's spine mirrors the usual acute and chronic lumbar spine injuries seen by sports medicine physicians. The golfer will typically recover from acute low back pain within 2 to 4 weeks. Relative rest and supportive treatment with analgesics followed by a gradual resumption of activities is adequate to manage most of these injuries. Pain lasting more than 2 to 4 weeks may be associated with more serious injury and can be accompanied by a decrease in range of motion, strength, and endurance. Physical therapy can help identify and address these imbalances when appropriate. Golfers with chronic back pain require a more comprehensive approach. Identification of functional deficits, including those that may be distant from the site of reported injury, is important. Professional golfers reporting low back pain within the previous year affecting play have been found to have decreased internal rotation of the lead hip (left hip in a right-handed player) and decreased lumbar extension compared with professional golfers who reported no such history [12»]. In senior golfers, these deficits are commonly observed, sometimes on the basis of mild to moderate degenerative change. These individuals can benefit from a structured rehabilitation program to address these deficits as well as changes in swing technique. Trunk stabilization and muscular coordination is an important part of rehabilitation after spine injury. Initiation of a core strengthening program becomes more important in golfers with chronic back pain. Improving strength and endurance of the abdominal and trunk musculature is important in preventing recurrent injury. This type of program has also been associated with an improvement in club head speed in driving distance [13]. Trunk stabilization should begin in a neutral, pain-free position. Golfers with back pain respond to the same treatment strategies as nongolfers, but require sport-specific rehabilitation and reintegration to the game. Instruction by a teaching professional to address swing faults can be extremely effective. Discussing the specific injury with the teaching professional can also be useful. For example, golfers who do not tolerate rotation through the lumbar spine can learn to increase the hip turn to increase power. The advice to "keep the head still" during the swing tends to prevent many golfers from making a good transfer of weight, resulting in acute lateral flexion concave to the dominant side (reverse G finish). Advising the teaching professional to pay special attention to specific cues regarding the setup posture can reinforce rehabilitation strategies. For instance, golfers with significant lumbar spondylosis may not tolerate a normal degree of lumbar extension; therefore, coaching the golfer to increase lumbar lordosis may not be productive. These individuals need to be coached to swing around a stable spine. This results in a significantly shorter backswing, but is less stressful to the spine and usually results in a more repeatable, reliable swing. Professional instruction in swing mechanics can be useful to the amateur as well as the professional golfer who is recovering from low back pain. In a case report of a professional golfer who recovered from chronic low back pain, treatment included a change in swing techniques resulting in increased hip turn and decreased shoulder turn [14]. Decreased trunk fiexion and lateral flexion during the downswing occurred with resulting decreased activity of the left erector spinae. These combined changes would be expected to decrease rotational stress and compressive load to the spine. Video motion and electromyographic analyses documented changes in swing technique, which allowed the golfer to return to professional play. Stress fracture of the ribs, thought to be related to weakness of the serratus anterior, has been observed in golfers [15]. These injuries typically occur on the nondominant side. As for spine injury, treatment includes relative rest until symptoms abate followed by progressive rehabilitation. Shoulder Pain Shoulder injuries affecting golfers occur predominantly in the nondominant shoulder. Inquiring about the timing and location of pain during the golf swing can be helpful. To get to the proper position at the top of the backswing, the nondominant shoulder goes into internal rotation, flexion, and horizontal adduction. This position may provoke pain originating from acromioclavicular (AG) joint osteoarthritis, impingement of the humerus on the anterior labrum, or posterior subluxation of the nondominant shoulder. During the downswing, the nondominant rhomboids, pectoralis major, and latissimus dorsi fire maximally from a lengthened position [16], and acute or repetitive injuries may occur to these structures. The nondominant shoulder is externally rotated and abducted at follow-through, which may exacerbate anterior instability symptoms. Pain on follow-through, laxity on drawer testing, and a positive apprehension and relocation test can support this diagnosis.
364 Competitive Sports and Pain Management Hovis et al. [17] described posterior instability of the nondominant shoulder in a series study of eight elite amateur golfers. Six of the eight also had impingement findings that were felt secondary to the posterior impingement. Six of these golfers failed nonoperative treatment and required arthroscopic electrothermal capsulorrhaphy, and four of these six required subacromial decompression. One golfer required reoperation. All golfers returned to their previous level of competition, with an average follow-up of 4.5 years. It is worth noting that these results are more favorable than results reported in a series of overhead-throwing athletes undergoing arthroscopic electrothermal capsulorrhaphy [18]. There is increased firing of the dominant supraspinatus and infraspinatus at take away. The supraspinatus of the nondominant shoulder shows increased activity as compared with the dominant shoulder throughout the golf swing, with the exception of take away. Otherwise, the rotator cuff fires at a low level during most of the golf swing. Most golfers tolerate impingement and rotator cuff problems in the dominant shoulder reasonably well, while symptoms from the nondominant rotator cuff typically interfere with the golf swing. The nondominant subscapularis fires through all phases of the golf swing, assisting in take away and firing to stabilize the humerus through downswing and follow-through. Most injuries to the rotator cuff respond to nonsurgical treatment, with rehabilitation emphasizing the rotator cuff, periscapuiar muscles, and any other deficits noted along the kinetic chain. Diagnostic evaluation may include plain films to exclude degenerative changes (especially at the AG joint) and other causes for shoulder pain. MRI can be useful in determining labral injury, impingement, rotator cuff tears, and other pathology, although one must be wary of false negatives and false positives. Judicious use of corticosteroid injection remains a widely used tool in treatment of rotator cuff injury. Surgical treatment is sometimes necessary in management of rotator cuff and labral injury, typically resulting in a successful return to golf [19]. As golfers age, AG and glenohumeral osteoarthritis become more common causes of shoulder pain. The nondominant AG joint is compressed during the backswing and pain originating at the AG joint has been found to be an important cause of shoulder pain in competitive golfers [20]. Pain typically occurs at the top of the backswing and is localized to the anterior shoulder. Treatment for AG joint osteoarthritis of the nondominant shoulder may include swing modification to incorporate a shorter backswing. Golfers respond to the same strategies as nongolfers, including relative rest, rehabilitation, corticosteroid injection, and distal clavicle resection if nonsurgical measures fail. Similar strategies can be effective for glenohumeral joint osteoarthritis. Rehabilitation, corticosteroid injection, and swing modification are effective strategies for many affected players. For those failing nonsurgical management, glenohumoral arthroplasty is an option. Jensen and Rockwood [21] reviewed 24 recreational golfers who had undergone shoulder arthroplasty (26 shoulder arthroplasties), finding that 23 were able to resume playing golf. The average length of time between joint replacement surgery and the first round of 18 holes was 4.5 months. Of the 18 golfers who maintained handicaps before and after surgery, the average improvement in postoperative handicap was five strokes, suggesting improvement in swing biomechanics subsequent to surgery. When compared with a group of 76 patients (103 arthroplasties), there was no increased evidence of loosening of the joint components. The authors also polled members of the American Shoulder and Elbow Society and found that 91% of these surgeons encourage resumption of golf after shoulder arthroplasty. Ninety-one percent of these surgeons also reported no observed increase in complications after shoulder surgery related to golf participation. Elbow Injuries Amateur golfers are more likely to injure the elbow, whereas professional golfers experience more injuries to the wrist [22»]. While many refer to medial epicondylosis as "golfers elbow," injuries to the nondominant lateral humeral epicondyle are much more common in amateur golfers. This injury is associated with gripping the club too tightly, which increases tensile load to the extensors of the wrist and fingers. A rehabilitation program combined with golf instruction is beneficial in helping the golfer recover from this injury. Because of the explosive tensile loading of the common extensor tendon during the golf swing, it may be advisable to avoid the golf swing to allow this injury to heal. This may be even more important if a corticosteroid injection is administered to treat this condition. Injuries to the medial epicondyle may occur in the dominant elbow as a result of contacting the ground before (or sometimes instead of) the ball, hitting off practice mats, hitting off hard, packed earth, or overuse. Experienced golfers are more likely to sustain injuries to the medial epicondyle as a result of overuse. Treatment of elbow injury in golfers includes all of the measures useful in nongolfers. Initial interventions may include relative rest, use of a counterforce strap, nonsteroidals to treat symptoms, and rehabilitation. Physical therapy may include physical modalities (iontophoresis, ultrasound, or phonophoresis), cross-friction massage, and stretching and strengthening exercises for the kinetic chain as appropriate. Association between lateral epicondylosis and weakness of the triceps and scapular muscles has been noted by physical therapists who work with golfers [23]. Some feel that the advice to "keep the left (nondominant) arm straight" leads to excess tension and the development of lateral epicondylosis on the nondominant side. Gorticosteroid injection remains widely used and is frequently effective, despite a lack of controlled
Musculoskeletal Problems in Golfers Wadsworth 365 evidence supporting its use. Acupuncture has been shown useful in treatment of this condition [24]. When the golfer is able to perform stretching and strengthening exercises without significant pain, a progression to the full swing can be introduced. Professional instruction can help prevent recurrence of this problem and sometimes hasten return to golf. Golf physicians and teaching professionals have noted an association between elbow injury and improper grip size, although this relationship has not been established in the literature. Conclusions Most golfing injuries can be treated by a combination of rehabilitation of the kinetic chain and professional golf instruction. For golfers not responding to nonsurgical interventions, surgical procedures may be successful in allowing the golfer to return to participation. References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: Of importance Of major importance 1. Quentin R: Jozi whizz kid has golfing success right down to a tee. Business Report 2003. Available at http://www. busrep.co.za/index.php?farricleid=244889. Accessed August 30, 2007. 2. Parkkari J, Natri A, Kannus P, et al.: A controlled trial of the health benefits of regular walking on a golf course. Am ] Med 2000, 109:102-108. 3. McArdle WD, Katch FI, Katch VL: Exercise Physiology: Energy, Nutrition, and Human Performance, edn 3. Malvern: Lea & Febiger; 1991. 4. McCarroU JR: The frequency of golf injuries. Clin Sports Med 1996, 15:1-7. 5. Batt ME: A survey of golf injuries in amateur golfers. Br J Sports Med 1992, 26:63-65. 6. McHardy A, Pollard H, Luo K: One-year follow-up study on golf injuries in Australian amateur golfers. Am J Sports Med 2007, 35:1354-1360. 7. McCarroll JR, Gioe TJ: Professional golfers and the price they pay. Phys Sportsmed 1982, 10:54-70. 8. Gosheger G, Liem D, Ludwig K, et al.: Injuries and overuse syndromes in golf. Am J Sports Med 2003, 31:438-443. 9. Watkins RG: Lumbar disc injury in the athlete. Clin Sports Med 2002, 21:147-165. 10. Hosea TM, Gatt CJ: Back pain in golf. Clin Sports Med 1996, 15:37-53. 11. Adams M, Hutton WG: The relevance of torsion to the mechanical derangement of the lumbar spine. Spine 1981, 6:241-248. 12.«Vad VB, Bhat AL, Basrai D, et al.: Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits. Am J Sports Med 2004, 32:494-497. Well-written association between specific, identifiable, and treatable range of motion deficits and low back pain in professional golfers. 13. Fletcher IM, Hartwell M: Effect of an 8-week combined weights and plyometrics training program on golf drive performance. / Strength Cond Res 2004, 18:59-62. 14. Grimshaw PN, Burden AM: Case report: reduction of low back pain in a professional golfer. Med Sci Sports Exerc 2000, 32:1667-1673. 15. Lord MJ, Ha KI, Song KS: Stress fractures of the ribs in golfers. Am ] Sports Med 24(1):118-122, 1996. 16. Pink M, Jobe FW, Perry J: Electromyographic analysis of the shoulder during the golf swing. Am J Sports Med 1990, 18:137-140. 17. Hovis WD, Dean MT, Mallon WJ, et al.: Posterior instability of the shoulder with secondary impingement in elite golfers. Am ] Sports Med 2002, 30:886-890. 18. Enad JG, ElAttrache NS, Tibone JE, Yocum LA: Isolated electrothermal capsulorrhaphy in overhand athletes./ Shoulder Elbow Surg 2004, 13:133-137. 19. Jobe FW, Pink MM: Shoulder pain and golf. Clin Sports Med 1996,15:55-63. 20. Mallon WJ, Golosimo AJ: Acromioclavicular joint injury in competitive golfers. / South Orthop Assoc 1995, 4:277-282. 21. Jensen KL, Rockwood GA: Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg 1998, 7:362-367. 22.«Wiesler ER, Lumsden B: Golf injuries of the upper extremity./ Swrg Orthop Adv 2005, 14:1-7. Excellent review of the nature and treatment of upper extremity injuries in golfers. 23. Jamieson S, McMaster R: Golf injuries: cause, effect and management. Golfmed.net Magazine 2004, 5:1-9. Available at: http://www.golfmed.net/magazine/newsletter/golfmed_ newsletter_juloct2004.pdf. Accessed July 31, 2007. 24. Fink M, Wolkenstein E, Karst M, Gehrke A: Acupuncture in chronic epicondylitis: a randomized controlled trial. Rheumatology (Oxford) 2002, 41:205-209.