Golf Injuries: Overview

The following is an overview of golf injuries including how, why, and who they occur to including comparisons between professional, amateur and the aging golfer.  Furthermore, a brief discussion on risk factors, swing considerations, and injury prevention strategies will be presented.  More detail of each will be presented in future articles, but this general overview serves to develop a background knowledge base for the athlete, parent, coach, fitness and medical professional.  It is quite long, so sit back, grab and Arnold Palmer and hopefully it will expand your knowledge base about injuries in golf.

Introduction

Over the last decade, an increase in the popularity of golf has been well documented.  An estimated 55 million people worldwide participate in the great game of golf!  With that, the number of courses in the USA, Europe, and Asia has increased tremendously.  With this increased accessibility and participation (among other things), an increase in injuries has also occurred.  Golf is usually described as a game that requires mild to moderate activity level; however, injuries in golf should not be underestimated or undervalued.  Additionally, many mechanisms and characteristics of injuries appear to be consistent with different skill and age groups who participate in the game.  Having an understanding of these consistent occurrences should facilitate the decision making process on developing strategies for prevention, rehabilitation, and enhancement of golf performance.

Golf Injuries in General

In general, golf injuries originate from either over-use or from a single traumatic event, and primarily affect the low back and upper extremity.  Amateur golfers have an annual prevalence of between 25.2-62% (1.19-1.3 per golfer per year), and the main risk factors appear to be low handicap and age over 50 years old.  On the other hand, in the professional golfer, it is closer to 88% or 2.0 injuries per golfer per year.  The higher prevalence in pro golfers is likely due to the increase practice times and repetitive nature of the game.

There are slight differences in regards to body parts affected, but in general the most common sites for injury are: Low Back (28-35%), Elbow (25-30%), Hand/ Wrist (15%), Shoulder (10%) followed by the lower extremity equally (hip, knee, ankle).

Who is at Risk for Golf Injuries?

Two primary groups of golfers are at risk for injuries: amateur golfers comprising of recreational and occasional, as well as professional golfers.  Occasional golfers are documented to be prone to injuries related to a poor knowledge of execution of golfing skills, resulting in traumatic injuries (usually at impact) or injuries related to badly executed golf swings.  In addition, amateurs in general are prone to overuse injuries due to various behaviors such as lack of warm-up, reduced mobility/ flexibility, limited strength, lack of physical conditioning, etc.

Competitive golfers (professionals and highly skilled amateurs) usually report soft tissue and musculoskeletal injuries associate with overuse.  This is usually due to the repetitive nature of the golf swing with intense or long practice sessions that cause imbalances in strength and range of motion predisposing these players to overuse syndromes.

Additionally, older golfers are considered “higher than normal risk” for injuries not only due to the nature of the game but also physiological factors associated with aging.

Injuries by Anatomical Location

Low Back and Trunk: As stated previously, the most commonly injured area is the low back.  However, reduction in participation was no more than one month for any episode of low back pain, and the most common injuries were minor which resulted in only one week of practice lost. Furthermore, the number of golfers with a history of LBP may be as high as 55% but it is unclear as to whether it is due to golf practice alone. Author’s note: This is consistent with orthopedic research regarding low back pain, which is said to be self limiting and resolving on its own in the majority of cases in 4-6 weeks.  Interestingly, the area of the body that has the largest practice time lost due to injury is the thoracic spine and not the lumbar spine.

Upper Extremity: Elbow injuries are the second most common, and moreso in amateur golfers than professional.  Medial epicondylitis (Golfer’s Elbow) occurs most in the right arm (for right handed golfers) usually due to repetitive resisted forces or from a single traumatic event like striking the ground and taking too large of a divot.  Lateral epicondylitis (Tennis Elbow) also affects amateurs more than pros, and occurs in the leading elbow.  The incidence of both conditions increases when the frequency of golf is increased (i.e. >2-3 rounds per week).  Interestingly, in amateurs Tennis Elbow is more prevalent than Golfers elbow!

Shoulder injuries are the third most common across the board, and most often related to overuse injuries due to excessive shoulder rotation at the top of the back swing and in the follow through.  In all reports, the leading shoulder was more commonly injured resulting in AC joint problems, impingement, rotator cuff tendonitis/ tears, instability, or arthritis.  Finally, wrist and hand injuries occur especially during forceful swings with high impact on the ground.

Lower Extremity: Lower limb injuries are no very prevalent in golfers, but it should be noted that the literature on the occurrence and mechanisms is limited.

Injury Distribution by Age

The average age for occasional golfers in the USA is 45 years old and one third of all American golfers are 50 years of age or older.  Not surprisingly, golfers 50-65 years old have the highest injury prevalence.  The reason for this is due to physiological changes that occur with aging such as changed in the musculoskeletal, cardiovascular, and neural systems.  Decline in strength, flexibility, coordination, bone and tendon resiliency and ability to deal with stress may increase rate of injury.  Author’s Note: This is another area of importance for the benefit of exercise in golf, but it is not the scope of this review and will be discussed later.  However, it should be noted that many of these declines in the aging adult can be mitigated with consistent resistance training due to the fact that type II muscle fiber (fast twitch) declines with age.  It is well documented that reduction of power and strength occur with normal aging, and with that a reduction in club head speed (golf’s demonstration of power) occurs between ages 40-59.

Mechanisms of Golf Injury

In amateurs that play an average of 2 rounds per week were most often injured by overuse, striking the ground with the club (hitting it “fat”), and poor swing mechanics.  Over-swinging, poor or incomplete warm-up, twisting of the trunk during the swing, and gripping too tight are other potential causes.  In professionals, overuse accounts for 80%, hitting it fat was 12%, and twisting of the trunk was 5%.  Professional golfers have almost negligable injuries due to poor swing mechanics, over-swinging, poor warm-up, or grip/swing changes.

Injury Versus Handicap

As mentioned several times, there are differences between professional and amateur golfers.  Professionals partake in regular competition and follow intense organized schedules of practice.  However, they are also usually engaged in carefully structured conditioning programs, and have better strength and flexibility indicators than recreational golfers.  Authors note: It is well documented that skill and fitness enhancement can reduce the risk of injury in other sports, why is it so hard to believe that golf would be any different? Spoiler alert…there is no difference!

Okay back the the details.  This next sentence is music to my ears!  Many problems detected in the amateur player  would probably disappear if a new and improved technique were adopted.  At the peak of the backswing, pro players were shown to exhibit significantly higher left shoulder horizontal adduction and right shoulder external rotation.  Professionals also have more trunk rotation at the height of the backswing and at the moment of ball contact.  How can you tell if you have enough trunk rotation? Click —> HERE.

Furthermore, low-handicap golfers who suffer LBP tend to demonstrate reduced erector spinae activity at the top of the backswing and impact, yet greater external oblique activity throughout the swing.  These findings are consistent with the “reverse spine angle” and “inverted-C” patterns.  More detail on these patterns are discussed —> HERE.  To piggy-back this idea, it is thought that this increased side-bending and early lumbar extension is a compensation from limited trunk rotation and frequently observed in recreational players.

Overall, low handicap golfers are injured more frequently than high handicappers, but the mechanisms and types of injuries are different.

Swing Phases and the Incidence of Injuries

With the understanding of how high club head velocities need to be reached in a short amount of time, it is easy to see that high stresses are applied to the body which can cause overuse or traumatic injuries.  Most articles separate the swing into several phases: (1) Ball Address, (2) Back-swing, (3) Down-swing, (4) Impact, (5) Follow-through.

With that said, most injuries occur at the end of the down-swing (18%) and follow-through (42%).  Many authors credit this to the high forces when the club is contacted with the ground and place emphasis on forearm muscle strength to maintain control of the club.  However, injuries may occur in any phase of the swing.

(1) Ball Address and (2) Back-swing: Ball address is characterized by adopting an optimal pre-stroke posture which may be different for some golfers but is generally an athletic stance with a neutral spine (flat back).  This posture will allow the golfer to generate maximal potential energy.  Structures may be stressed due to compromised starting position including: excessive loading of the spine through hyper-extension.  During the back-swing, shoulder injuries can occur through compression of the rotator cuff or sub-acromial bursa, or from instability of the lead shoulder.  Likewise, over-rotation of the trunk during the back-swing can cause injury.

(3) Down-swing and (4) Impact: It has already been established what forces occur during impact and the effects on the wrist/hand/elbow, yet the downswing has not been discussed.  Injuries during the downswing (and even impact) occur in the range of movement of greatest muscle activity.  Players who are less skilled have up to 50% less trunk rotational capacity than younger more skilled players.  This means that to compensate and be able to hit the ball as far, a higher muscle activity will be demonstrated.  Thus, higher loading of the spine is a result due to reduction in flexibility, strength and stabilization of the trunk/ spine.  This is another important reason for optimizing mobility and stability (i.e. strength and conditioning).

(5) Follow-through: During the follow through there is a rotary motion of the hip and shoulders so that the body faces the target.  With this, the lumbar spine is at risk for injury if the deceleration stops too briskly or if the final motion is too pronounced (ex. reversed “C” or over rotation).  To minimize excessive spinal load the spine should be vertical at the end of the follow through.

As for the shoulder musculature and rotator cuff in particular, the supraspinatus and infraspinatus of the lead arm are activated primarily during follow through, while the subscapularis remains active during the forward swing and ball impact.  Thus, these muscles are not only important for stabilizing the shoulders during the swing, but also during the follow through.

Summary

• The general nature of the golf swing and subsequent injuries is quite similar among golfers.
• Recreational golfers are more likely to suffer traumatic injuries from bad technique, insufficient warm-up and poor physical fitness.
• Competitive and professionals are usually affected by overuse injuries which stem from strength and range of motion imbalances.
• Low back pain is the most common complaint but its not clear if it is related to golf practice.  Find out more here.
• Shoulder problems are also common, with the lead shoulder being more often reported.
• Elbow injuries are second most common, with tennis elbow being more prevalent than golfer’s elbow.
• Traumatic and impact injuries are more common in young or old players, and players with low skill levels.

If you enjoyed this post, but are interested in more detail about specific injuries and their prevalence in golfers, we have you covered!

 

 

 

 

 

References

Cabri J, Sousa JP, Kots M, Barreiros J.  Golf-related injuries: A systematic review.  European Journal of Sport Science. 2009; 9(6):353-366.