While golf is not typically an activity associated with macrotraumas (like football or hockey), its repetitive motions can nevertheless result in numerous types of strains and injuries for the professional and amateur alike. This article is dedicated to reviewing the medical literature on that topic with an eye to some preventative and remedial treatments for the amateur. Currently some 17.6% of Canadians over 15 enjoy playing golf. Indeed, the nature of the sport allows it to be performed by people of almost all ages and for much of their lives. Whereas to an onlooker it may appear to be a leisurely activity, it is in fact quite physically demanding, something revealed by its associated injuries. They can involve a number of different tissues; however, repetitive strain injuries (RSIs) to muscle and tendon are the most common. Related joints include those in the foot, ankle, knee, hip, back, shoulder, neck, elbow, wrist and in the hand — thus, much of the skeleton. Beyond that, blood vessel damage in the hand, stress fractures in the leg and rib cage, and a variety of nerve entrapments are also possibilities. One study reported that 45% of amateurs and 54% of professionals considered their injuries to be chronic. Table 1: Major amateur golfing injuries: female male total lower back 27.4% 35.9% 34.5% elbow 35.4 32.5 33.1 medial (elbow) 27.4 27.4 27.4 lateral (elbow) 8.1 5.1 5.6 hand and wrist 14.5 21.2 20.0 shoulder 16.1 11.0 11.9 knee 11.3 8.9 9.3 neck 1.6 4.5 4.0 hip 3.2 3.0 3.1 McCarroll, J.R. (1996) “The frequency of golf injuries.” Clinics in Sports Medicine 15(1):1-7. While RSIs can occur throughout a game — i.e., the “yips” during putting —, by far the most physically stressful and demanding portion is the swing. Within a fraction of a second the speed of the club prior to hitting the ball can reach 160 km/h, something which is repeated on average 50 times per 18-hole course for the amateur and >300 times during a professional’s practice session. Poor initial set-up while addressing the ball can potentiate RSIs during the subsequent 5 phases — the backswing, forward swing, ball impact, early follow-through, and late follow-through. Whereas that may be a determining factor for the newer player, the incidence of injury of a seasoned one indicate it is not the only one (see table 2). Table 2: Major professional golfing injuries: PGA LPGA total left wrist 16.1% 31.3% 24.0% lower back 25.0 22.4 23.7 left hand 6.8 7.5 7.1 left shoulder 10.9 3.0 7.1 left knee 7.0 6.0 7.0 left elbow 3.1 4.5 3.8 left thumb 5.2 1.5 3.3 foot 2.1 4.5 3.3 McCarroll, J.R. (1996) “The frequency of golf injuries.” Clinics in Sports Medicine 15(1):1-7 At 34.5%, low-back pain is the prevalent condition. In golf all four types of force come into play on the lumbar spine — lateral bending (lateral flexion), shear (frontward and backwards), compression and torsion/rotation. Compared with professional players, amateurs tend to generate ~80% more peak lateral bending and shear and ~50% more torquing in the mid-lumbar. Compression forces can be between 6000 and 7500 N; disc prolapse can occur at 5448 N. Consequently, pain tends to involve lumbar strains and muscular spasms, intervertebral disc herniations, and degeneration of the vertebrae (spondylolysis) and facet joints (facet arthropathy). Running a close second are inflammatory conditions of the elbow, notably “golfer’s elbow” (medial epicondylitis) in the dominant arm and “tennis elbow” (lateral epicondylitis) in the lead arms. While the condition can be associated with localised pain due

to tightness in the extrinsic flexors and extensors of the hand, respectively, up to 20% of those with medial epicondylitis can have numbness in the outside of the palm and fingers due to entrapment of the ulnar nerve. Next are conditions of the wrist and hand. Using an example of a right-handed player, the reorientation of the wrist from the back swing to the final stage of follow-through can result in 103º change from extension to flexion and 45º from radial to ulnar deviation (side-to-side movement) in the right wrist. The left wrist undergoes similar changes, though less dramatic: 71º and 46.5º, respectively. For both that is beyond the normal functional demands, thereby making the golfer susceptible to injury. de Quervain’s Disease — inflammation of the tendons of the short extensor and long abductor of the thumb — may also develop. Yet another source of pain and joint contracture is tenosynovitis of the finger flexors, resulting from inflammation of the lining of the tendon sheath. Finally with respect to the hand and wrist, two other conditions may arise: carpal tunnel syndrome and hypothenar hammer syndrome. As a result of changes in the way the club is held, in some players compression of the hook of the hamate bone in the hand against the nearby distal ulnar artery, thereby blocking blood flow and resulting in pain amongst other signs and symptoms. Lastly for the purposes of this article is shoulder pain. As with the motions of the wrist and lower back, so too are the shoulders forced to endure tremendous stress, notably at the top of the back swing and top of the flow-through. In the younger player (under 35 years of age) rotator cuff tendinitis and inflammation of the back of the joint capsule are more common. Around that age, degeneration begins to occur, predisposing those players over 35 to other injuries. The joint which feels like a shelf over the bone of the upper arm (the humerus) — the acromioclavicular joint — may develop spurs which press against the rotator cuff potentially resulting in partial tears. Arthritic conditions may set in and degeneration of the cartilage at the front and back of the head of the humerus may occur. Such microtraumas can lead to instability in the shoulder and eventual restrictions in range of motion. Staying the course “An ounce of prevention is worth a pound of cure.” Given that almost all of the injuries in golf are RSIs, that adage is quite apropos. Maintaining the dynamic flexibility of muscles needs to be a goal of all players. That can be supported with a proper, supervised stretching programme which one diligently follows prior to each course. While it would be possible to describe them here, it is best to have them demonstrated, as small variations in some of them can lead to more strain. That service is provided by all therapists at the Centre as part of treatment. In many cases, however, chronic overuse will have resulted in shortening of many postural muscles which will need temporary, remedial treatment. The goals include reducing associated pain; decreasing tautness; eliminating trigger-point activity and any referred pain arising from it; and increasing restricted range of motion. To illustrate that point, one need only turn to the example of shortening of one muscle in the low back: the quadratus lumborum. It is located fairly deep, attaching the last rib to the hip crest and the lumbar vertebrae to both. As it tightens it starts to tilt one over to the same side. Typically, another muscle that helps keep one upright (located on the back to the side) tightens with it. If they are too taut, one will not be able to turn to the opposite side well. Thus, for a right-handed golfer, tightness on the left side would restrict the back swing while that on the right would limit the follow-through. Compensation may occur at the shoulder with additional strain on the rotator cuffs and joint capsule...and so on. Given that which has been written above and that golfers do experience stress fractures in the ribs, the importance of keeping muscles strong yet loose is clear. Should you have any questions or wish to book a treatment, please give us a call.

Bibliography

Adlington, G.S. “Proper swing technique and biomechanics of golf.” Clinics in Sports Medicine 15(1): 9-26.
Clancy, W.G.; Hagan, S.V. “Tendinitis in golf.” Clinics in Sports Medicine 15(1): 27-35.
Gregori, A.C.P. “Tibial stress fractures in two professional golfers.” Journal of Bone and Joint Surgery 76B(1): 157-158.
Grimshaw, P.N.; Burden, A.M. “Case report: reduction of low back pain in a professional golfer.” Medicine and Science in Sports and Exercise 32(10):1667-1673.
Guten, G.N. “Knee injuries in golf.” Clinics in Sports Medicine 15(1): 111-128.
Hosea, T.M.; Gatt, C.J. “Back pain in golf.” Clinics in Sports Medicine 15(1): 37-53.
Jobe, F.W.; Pink, M.M. “Shoulder pain in golf.” Clinics in Sports Medicine 15(1): 55-63.
Kohn, H.S. “Prevention and treatment of elbow injuries in golf.” Clinics in Sports Medicine 15(1): 65-83.
Kreitner, K.-F.; Düber, C.; Müller, L.-P.; Degreif, J. “Hypothenar hammer syndrome caused by recreational sports activities and muscle anomaly in the wrist.” Cardiovascular and Interventional Radiology 19 (1996): 356-359.
McCarroll, J.R. “The frequency of golf injuries.” Clinics in Sports Medicine 15(1): 1-7.
Müller, L.-P.; Müller, L.-A.; Degreif, J.; Rommens, P.M. “Hypothenar hammer syndrome in a golf player: a case report.” American Journal of Sports Medicine 28(5): 741-745.
Murray, P.M.; Cooney, W.P. “Golf-induced injuries of the wrist.” Clinics in Sports Medicine 15(1): 85-109.
Pietrocarlo, T.A. “Foot and ankle considerations in golf.” Clinics in Sports Medicine 15(1): 129-146.
Pink, M.M.; Jobe, F.W; Yocum, L.A.; Mottram, R. “Preventative exercises in golf.” Clinics in Sports Medicine 15(1): 1147-162.
Selicki, F.A.; Segall, E. “The mind/body connection of the golf swing.” Clinics in Sports Medicine 15(1): 191-201.
Stover, C.; Stolz, J. “Golf for the senior player.” Clinics in Sports Medicine 15(1): 163-178.
Thériault, G.; Lachance, P. “Golf injuries: an overview.” Sports Medicine 26(1): 43-57.

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