Managing Golf Injuries
Technique and Equipment Changes That Aid Treatment
CAPT John P. Metz, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 7 - JULY 1999
In Brief: Proper golf technique and equipment and preventive measures can minimize golf-related injuries of the back, shoulders, elbows, and hands and wrists. Rotating the shoulder and hip a similar amount during the backswing and keeping the spine vertical during the follow-through can reduce lumbar spine strain. A rigid back support may lower the risk of vertebral compression fracture in osteoporotic patients. Shortening the backswing can decrease pressure on a degenerative acromioclavicular joint. Therapy for 'golfer's elbow' includes medial counterforce bracing, larger club grips, and graphite shafts. Treatments for wrist and hand disorders include proper swing and grip technique and larger, softer grips. Diagnosis of the easy-to-miss fracture of the hook of the hamate may require tomogram, CT, or MRI.
Golf has become increasingly popular in the 1990s. Between 1991 and 1994, 350 golf courses per year were newly constructed or expanded, nearly twice the rate of the mid-1980s (1). By 1994, the United States had 14,000 golf courses, and in 1996 there were over 20 million players (2) of all ages competing at all skill levels.
Compared with many other sports, golf appears to be relatively benign in its potential for injury. However, the game stresses the body in unique ways that can lead to acute and chronic injuries. Given golf's growing popularity, primary care physicians need to be aware of golf-related injuries. Familiarity with the game's basic biomechanics and techniques and the patterns of injury common in various types of players can facilitate the diagnosis, treatment, and prevention of golf-related injuries.
The Golf Swing
The golf swing is a complex, coordinated movement of the hands, wrists, arms, trunk, and legs. It can be broken into four phases: backswing, downswing, acceleration and ball strike, and follow-through (3).
Backswing. This phase involves rotating the trunk, raising the arms, and cocking the wrists while pulling the club head away from the ball in a smooth and coordinated motion toward the player's "trailing" side. (A golfer's "leading" side is toward the target and the trailing side is away.) Eventually the club head is positioned above and behind the golfer's head (figure 1), where the downswing begins.
Downswing. The club is swung toward the ball by using the shoulder and wrist levers created in the backswing. In a smooth motion, the body turns toward the target, the arms swing down, and the wrists start to uncock. This phase ends when the shaft is parallel to the ground.
Acceleration and ball strike. This is the quickest part of the swing. The arm and trunk motions started in the downswing continue, and the wrists and forearms are rapidly uncocked, the leading wrist supinated, and the trailing wrist pronated to maximize the speed of the club head as it connects with the ball (figure 2).
Follow-through. After the ball is struck, the natural momentum of the swing continues, with the club head ending above or even behind the player (figure 3).
Though the golf stroke involves the coordinated movement of the whole body, injuries of the hands, wrists, arms, and trunk are the most common. Most golfers swing with a right-handed stance, and the left or leading side of the body is more commonly injured than the right or trailing side (4). The prevalence of injury, however, varies depending on a number of factors, including gender and professional vs amateur status (table 1).
In one survey (5), the most commonly injured sites in amateur golfers overall (by percentage of players injured at each site) were the lower back (34.5%), elbows (33.1%), hands and wrists (20.1%), and shoulders (11.7%). Men had virtually the same percentages as the group overall, but the most common sites of injury in amateur women were the elbows, followed by the lower back, shoulders, and hands and wrists.
In contrast, professional male and female golfers most often injured their hands and wrists, followed by the lower back, shoulders, and elbows, though percentages differed somewhat by gender.
Injuries in amateurs, who play an average of two rounds a week, are most often due to overuse (25%), striking the ground with the club (hitting a "fat shot," 21%), and poor swing mechanics (19%) (5). "Overswinging" (swinging harder and/or faster than is appropriate for a golfer's capabilities), poor warm-up, twisting the trunk during the swing, and grip or swing changes also contribute to amateurs' injuries (6). In professionals, who play many hours a day on most days, overuse accounts for 80% of injuries, hitting a fat shot for 12%, and twisting the trunk during the swing for 5%. Professional golfers report no injuries due to poor swing mechanics, overswinging, poor warm-up, or grip or swing changes (6).
Golfers who have a lower handicap (0 to 9) are slightly more likely to be injured than those who have a handicap higher than 18 (67.5% vs 59%). The career injury rate in golfers older than 50 is slightly higher than that in younger golfers (64.9% vs 58.3%) (5).
Given these patterns of injury, primary care physicians will undoubtedly treat golfers who have injured their back, shoulders, elbows, hands, or wrists. Of course, the basic principles of injury prevention and treatment apply (rest, immobilization, ice and/or heat, anti-inflammatory drugs [NSAIDs], stretching, strengthening, proper warm-up, injections, and, if necessary, surgery), but the focus here is on treatment and prevention strategies related to the golf swing and equipment.
During the golf swing, the lumbar spine is subjected to forces of lateral bending, anteroposterior shearing, caudocranial compression, and rotation. The lumbar spine of an amateur, however, undergoes significantly more loading than that of a professional (2).
Lumbar spine loads and injuries. Amateurs generate greater myoelectric activity in the muscles of the lumbar spine (L-3 through L-4) and therefore greater calculated spinal loading forces than professionals (2). They reach 90% of their peak muscle activity during a golf swing, while professionals reach about 80%. Although peak compression loads normalized for body weight are identical for amateurs and professionals, amateurs generate 80% greater lateral bending and peak shear loads and 50% more torque than professionals. Amateurs also lack the organized muscle firing patterns characteristic of a professional's "grooved swing" (a swing that is virtually the same every time, indicative of swing refinement, countless repetitions, and coordinated muscle firing). Amateurs' greater spinal loading and muscle activity during the swing are mainly caused by poor swing mechanics, which only increase the loads as they swing harder—instead of more skillfully—to hit the ball farther.
The resulting increased loads may predispose amateur golfers to muscle strains, herniated nucleus pulposus, and facet arthropathy of the spine (2). In fact, loads that cause disk disruption in cadavers are similar to the loads present during the golf swing. However, one study (7) showed that golfers' risk of developing a herniated lumbar disk is 0.59 relative to those who play no sports and that those who play at least two times a week have a relative risk of 0.19.
Reducing lumbar spine strain. The strain on the lumbar spine may be reduced by adjusting the golf swing in two ways. First, a backswing that minimizes the difference between shoulder rotation and hip rotation will help reduce the amount of rotation and resulting strain in the lumbar spine. Second, a follow-through with the spine perpendicular to the ground is much gentler on the lumbar spine (figure 3a) than the "reverse C" finish (figure 3b), in which extreme hyperextension puts a large load on the lumbar facet joints.
Vertebral compression fracture. Vertebral compression fractures may occur in golfers who have osteoporosis, an important consideration since golf is not limited to the young. One case series (8) included three osteoporotic women who suffered upper lumbar and lower thoracic vertebral compression fractures while swinging a golf club. Such an injury is understandable, because the lumbar spine undergoes a compressive load about eight times a person's body weight during the golf swing, which may be enough to cause vertebral compression fractures in osteoporotic spines (2).
The authors of the case series recommend that golfers at risk for or known to have osteoporosis be warned of this hazard. They also suggest that these golfers wear a rigid back support that restricts spinal rotation to decrease the risk of injury. However, no studies confirm the validity of this recommendation.
Rib stress fractures. Golfers can also suffer thoracic back pain from stress fractures of the ribs. In one study (9), 18 cases occurred in novice golfers (average length of play, 8 weeks) and 1 in an experienced golfer who had just dramatically increased his playing and practice time. All fractures were on the posterolateral aspect of the ribs, and most involved the fourth to the sixth ribs. Fifteen were on the golfer's leading side, 3 on the trailing side, and 1 was bilateral.
Weakness in the serratus anterior muscle on the leading side is believed to cause muscle fatigue that eventually leads to stress fracture (9). This is certainly plausible, since the leading serratus anterior is nearly constantly active throughout the golf swing and thus may be subject to fatigue (10).
Diagnosis is relatively straightforward, with either plain radiographs or a bone scan. Treatment is similar to other stress fractures, including relative rest, NSAIDs, and scapular muscle rehabilitation.
Shoulder pain in golfers is usually caused by overuse rather than any specific component of the swing itself (11). During the golf swing, the leading shoulder is subject to an extreme range of motion, from internal rotation and adduction across the body at the top of the backswing to abduction and external rotation at the end of the follow-through. This broad range increases the risk of injury.
In a study (12) of 35 competitive golfers—professionals and those with a handicap below 3—who had shoulder pain, 34 (97%) had pain in the leading shoulder. The acromioclavicular (AC) region was most commonly affected (53%). Other causes of shoulder pain included impingement or rotator cuff tendinitis (26%), posterior glenohumeral subluxation (12%), rotator cuff tear (6%), and glenohumeral arthritis (3%). The forces across the AC joint are greatest at the top of the backswing and at the end of the follow-through.
EMG studies. Electromyographic (EMG) studies (13,14) of the shoulder and scapular muscles in professional golfers may shed some light on the causes of these injuries. These studies show that the subscapularis is the most active of the four rotator cuff muscles throughout the swing. Both deltoids are relatively inactive throughout the swing, while the pectoralis major and latissimus dorsi are the most active during the downswing, contributing significantly to the swing's power. The scapular muscles—levator scapulae, trapezius, rhomboids, and serratus anterior—are about equally active throughout the swing and, more important, exhibit a highly coordinated firing pattern that allows both scapulae to rotate around the trunk as a unit during the swing.
These findings suggest that the shoulder and scapular muscles must be well coordinated for the arms to function effectively during the swing. Though there are no studies that compare shoulder muscle activity in amateurs and professionals, disordered shoulder muscle firing is probably more likely in amateurs—as is the case in the muscles of the lower back discussed above. This misfiring could lead to rotator cuff fatigue and injuries—which reportedly occurred in 79 of 85 amateur golfers at one clinic who had shoulder pain—and to scapular muscle injuries (13).
Diagnostic clues. The site of shoulder pain can offer diagnostic clues. At the top of the backswing, pain in the anterior aspect of the leading shoulder is usually due to degenerative changes in the AC joint or to impingement; pain in the posterior aspect is due to shoulder capsule tightness. During follow-through, posterior pain in the leading shoulder is due to impingement.
Treatment tips. One way to reduce the stress on the AC joint of the leading shoulder without sacrificing club head speed is to shorten the swing by ending the backswing with the club head at a 1 or 2 o'clock instead of a 3 o'clock position. Conditioning the rotator cuff and scapular muscles with light weights or other resistance training may also help. Developing a grooved swing, with the help of a golf pro to ensure proper mechanics, can also be useful. To generate power, golfers should strengthen the pectoralis major and latissimus dorsi muscles.
Medial epicondylitis ("golfer's elbow") in the trailing arm and lateral epicondylitis in the leading arm are common elbow injuries; amateurs develop the condition laterally about five times more frequently than medially (5). The incidence increases with age and the number of rounds played, with more than two to three rounds per week as a threshold for increased incidence. These disorders are most frequently associated with overuse and excessive grip tension. Proper grip tension optimizes the function of the forearm muscles, allowing smooth, rapid pronation and supination of the forearms and reduced stress on the wrist flexor and extensor tendon insertions at the elbow (15).
Golfer's elbow. Medial epicondylitis is associated with distinct EMG activity in the wrist flexor muscles of symptomatic golfers. Those who have this condition show increased activity throughout the swing, while asymptomatic golfers have only a burst of activity just before, during, and after ball contact (16). These patterns of EMG activity are the same whether the golfers have a high handicap (9 to 19) or a low handicap (1 to 7).
Two common therapies for golfer's elbow are medial counterforce braces and larger club grips. The EMG activity in the wrist flexor group in symptomatic golfers shows no change with these therapies (16), but some authorities still recommend their use (15). Medial counterforce braces may provide some symptom relief by changing the effective length of the wrist flexor muscles, which relieves tension on the flexor tendon without changing muscle activity patterns. The effectiveness of larger grips is still unclear, because they do not change muscle activity or relieve symptoms (16). Neither therapy changes a patient's swing mechanics, which may be the root of his or her elbow problems.
Swing mechanics. Whether a golfer is suffering from medial or lateral elbow pain, improved swing mechanics can bring relief. Particularly important is correct swing plane—the plane that the club shaft describes during the backswing and downswing. If it is too steep (ie, too close to perpendicular to the ground), the hands and wrists overcompensate to position the head for ball impact, increasing the risk of hitting a fat shot, which transmits decelerative forces to the hands, wrists, and elbows. If the swing plane is too flat (ie, too close to parallel to the ground), the elbows undergo undue stress. Proper swing mechanics also require correct wrist technique, which is addressed below.
Equipment. Changing equipment may help, too. Using cavity-backed irons that have larger heads and "sweet spots" will dampen the vibrations transmitted to the wrists and forearms from off-center hits. Graphite shafts are more flexible than steel shafts and will reduce vibrations from hitting fat shots. A professional golf shop can help select club heads and shafts for a golfer based on his or her swing.
Wrists and Hands
Wrist position changes rapidly during the golf swing. Cahalan et al (17) found that, in the frontal plane, the trailing and leading wrists' average arc of motion is 103° and 35°, respectively. Corresponding figures in the sagittal plane are 31° and 36°. At the moment of impact, the leading wrist is ulnarly deviated 23°. The wrists contribute to club speed during the golf swing; one study (18) measured the club's average angular velocity at 27.6°/0.01 sec and average club-head speed at 46.6 m/sec just before ball impact.
These figures suggest a potential for wrist injuries, which are among the most common injuries in pro players. In one study (17), golfers who had a variety of pathologic conditions of the hands, wrists, and forearms had decreased range of wrist motion and handgrip strength when compared with asymptomatic golfers. However, the leading wrists of symptomatic golfers had an increased arc of motion in the frontal plane (68°) and sagittal plane (58°) and increased ulnar deviation (58°) at the moment of impact. The authors suggest that weakness in the forearms, wrists, and hands prevented adequate wrist control during the swing, causing excessive motion and persistent pain and injury.
Whether excessive wrist motion is a cause or a result of injury remains unclear. Nevertheless, strengthening the forearm muscles to help reduce undue wrist motion during the swing could bring relief in similar patients.
Tendon disorders. De Quervain's disease—painful tenosynovitis of the common tendon sheath of the abductor pollicis longus and extensor pollicis brevis (figure 4)—is often seen in individuals whose activities require a forceful grasp and ulnar deviation of the wrist or repetitive use of the thumb (19). In golf, the ulnar deviation of the leading wrist at ball impact may stress the tendons in the first dorsal compartment. In addition, an amateur golfer may improperly employ the "casting maneuver," prematurely uncocking the wrists at the beginning of the downswing rather than during the acceleration and ball-strike phase. This results in ulnar deviation of the leading wrist too early in the swing, which traps the leading thumb between the trailing hand and shaft and stresses the tendons in the first compartment. The casting maneuver also increases the risk of extensor carpi ulnaris tendinitis (20).
Hitting a fat shot can put significant stress on the extensor carpi ulnaris of the leading arm and flexor carpi radialis and ulnaris of the trailing arm; in fact, fat shots have been known to cause tendinitis in all three tendons and even subluxation and dislocation of the extensor carpi ulnaris tendon of the leading wrist (21). Proper swing mechanics and a grooved swing help prevent fat shots, and, as previously stated, flexible golf shafts can absorb the shock of these shots.
Stenosing tenosynovitis of the index finger (trigger finger) may occur in the leading hand because of excessive grip tension that can irritate the first annular pulley. There are no studies of trigger finger in golfers, but reason would suggest that larger, softer grips may help prevent too tight a grasp and reduce flexion of the metacarpophalangeal and proximal interphalangeal joints. If this measure fails, using a neutral grip rather than a strong grip (figure 5) may change the placement of the club in the palm and reduce the irritation of the first annular pulley.
Fractures. Fractures in golfers are uncommon, but fracture of the hook of the hamate ("golfer's wrist," figure 6: not shown) deserves mention. Hamate fractures account for about 2% of all wrist fractures, but 33% of hamate fractures are found in golfers (20). It is the most common fracture in golf and often goes undiagnosed for several weeks to months. This injury is caused by a fat shot, especially one in which the club head strikes a relatively heavy or immovable object, such as a rock or root. The butt of the club is forced against the hypothenar region of the leading hand, breaking the hook of the hamate.
Symptoms include hypothenar pain that increases with gripping, grip weakness, and ulnar nerve paresthesias. Signs include localized tenderness and painful resisted flexion of the little finger, since the flexor and opponens digiti minimi originate from the hook of the hamate (22).
Standard wrist radiographs often fail to reveal this fracture. A carpal tunnel view or an oblique view of the wrist with the forearm supinated 45° and the wrist dorsiflexed may show it (23). However, wrist tomography, computed tomography, or magnetic resonance imaging is usually necessary.
If this fracture is diagnosed early, treatment is 6 to 8 weeks in a short arm cast. Most of these fractures, however, are diagnosed late, and surgical excision of the fracture fragment is required.
Preventive measures include using clubs of the proper length and with properly sized grips. The butt of the club should extend slightly beyond the palm of the leading hand rather than dig into the hypothenar region (24).
Consulting a Golf Professional
Many of the injuries common in golfers are closely related to golf technique and equipment. Understanding the biomechanics of the swing and how technique and equipment affect the body can facilitate diagnosis, treatment, and injury prevention. Many books and magazines offer solutions to golfers' technical problems and related physical disorders, but a good teaching golf professional may be the most useful source of information for patients who have golf-related injuries. Clinicians should not hesitate to suggest that patients consult such professionals regarding technical and equipment issues related to these injuries.
Dr Metz is a family physician in the US Air Force, practicing in the 51st Medical Group at Osan Air Base in the Republic of Korea. He is a member of the American Academy of Family Physicians. Address correspondence to John P. Metz, MD, 1504 Shadywood Ct, Crofton, MD 21114-1145; e-mail to [email protected].