Benjamin J. Ingram
Gregory G. Dammann
Golf was invented in the 12th century in Northern Europe (16).
The first golf course was built in the United States in 1888 (4). At the beginning of the 21st century, 29.5 million golfers played on 15,000 golf courses in the United States. In total, 55 million golfers play on 30,000 golf courses worldwide (1,3).
The National Sporting Goods Association estimates that 18-20 million Americans play golf at least two times per year.
As a sport, golf is classified as a noncontact, low-intensity sport; therefore, only moderate cardiovascular fitness is required.
Most injuries result from the golf swing, the equipment, or objects, including the ball, on the course.
THE GOLF SWING
For definition in this chapter, for the right-handed golfer, the dominant side is the right or trailing side and the nondominant side is the left or leading side. The left-handed golfer would reverse left and right in regard to dominance.
There are two types of swings in golf: “modern” (in common use since the 1960s) and “classic” (5).
The modern swing is comprised of multiple coordinated movements of different parts of the body: the hands, wrists, arms, trunk, and legs.
There are four phases:
Backswing or take away: Rotation of the trunk, raising the arms, and cocking the wrists while drawing the club head away from the ball. This is often called coiling.
Downswing or forward swing: Movement of the club head toward the ball using the shoulders and uncocking of the wrists. Often called uncoiling.
Acceleration and ball strike: The arms and trunk continue to rotate back toward the ball and the wrists are uncocked. The leading wrist also supinates while the trailing wrist pronates. This is the fastest portion of the swing.
Follow through: Momentum of the swing continues with rotation of the shoulders and trunk while raising the arms (5).
Annual injury rate is around 40% (2).
Injuries are different for professional and amateur golfers.
Amateur golfers most often injure the lower back and elbow with conflicting evidence on the most common site (15,21,23).
In amateurs, 25% of injuries are from overuse, 21% are from hitting the ground with the club during the swing, and 19% are from poor swing mechanics (13).
Professional golfers most frequently injure the lower back, followed by nondominant wrist and shoulder injuries. Professional golfers report fewer elbow injuries than their amateur counterparts (15,21).
Eighty percent of professional injuries occurred secondary to overuse, 12% occurred from hitting the ground during the swing, and 5% occurred from twisting the trunk (excessive torque) during the swing (12).
It is unclear whether stretching for increased flexibility prevents golf injury (2).
Golfers walk approximately 3 miles during 18 holes of golf (2).
LOWER BACK INJURIES
The lower back is the most common injury in professional and amateur golfers (23.7%-34.5% of all injuries) (15).
The professional golfer has a more efficient and smoother swing than amateur counterparts, but professional golfers still have the highest incidence of low back pain of all professional sports (21).
The lumbar spine rotates, side bends, compresses, flexes, and hyperextends during the golf swings. These movements result in lateral bending, shear, compression, and torque forces. The shear and torque forces are 80% significantly higher in the amateur compared to the professional golfer (4,21).
The modern swing ends the follow-through phase in the “reverse C” (lumbar hyperextension) (18). “Crunch factor” describes the lumbar lateral bending that takes place during the swing (5). Reverse C and crunch factor can be more pronounced in amateur golfers. Explanations for this difference
include inadequate weight transfer during the swing, a more varied stance, leaning away from the ball at impact and follow-through, and less hip turn than allowed in the classic swing (4,5,15,21). The professional’s swing is more smooth and refined from repetition, which results in coordinated muscle firing throughout the swing and a more upright stance at the end of follow-through (5,17).
These forces put golfers at risk for muscle strains, herniated nucleus pulposus (HNP), facet arthropathies, and spondylosis/spondylolisthesis.
Lumbosacral strains typically occur during activity and are relieved with rest. There is tenderness over the affected soft tissue area and no radiologic abnormalities.
HNP and sciatica are almost always associated together. Ninety-five percent of all HNPs occur at L4-L5 or L5-S1, and these nerve roots provide sensory and motor functions to the lower extremity (4).
Facet arthropathies and spinal stenosis are related as a dysfunction that develops at the posterior facet joints producing a narrowing of the spinal foramen. The pain is often increased with extension and side bending to the affected side.
Spondylolysis (defect in pars interarticularis) can occur from the significant torque produced during the coiling and uncoiling of the lumbar spine. This torque causes fractures at the pars interarticularis. With a pars defect, especially bilateral, there is the potential for spondylolisthesis (anterior displacement or sliding of the affected vertebrae) (18). This displacement can cause impingement of the spinal nerve roots or cord.
Additionally, golf bags are traditionally carried on one shoulder, leading to asymmetric loading (2). Newer bags have the ability for two-shoulder carry or use of a rolling pull cart. Additionally, most golf carts have an area for carry of golf bags.
Most injuries can be managed conservatively because greater than 90% of patients recover in 4 weeks after injury (4); however, some “red flags” should alert the clinician of underlying pathology: back pain in a patient over 50 or less than 20 years old; a history of cancer; constitutional symptoms of fever, night sweats, weight loss, and the like; bowel and/or bladder dysfunction; and saddle anesthesia. If any of these are positive, a more complete workup with imaging studies would be indicated. If no red flags are present, the patient should be encouraged to perform activities that their pain tolerance allows (active rest) and to use ice and acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as required (5
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