Golf seems like a gentle, innocuous sport. Yet even among professional touring players, injuries happen: on average they sustain two injuries a year(1) and lose five weeks of playing time.
Professionals generally suffer as a result of overuse; among amateurs most problems go back to poor technique, especially swing mechanics or technical errors near impact.
The most common injury site in male professional golfers is the back, followed by the left wrist and shoulder. Female professionals are more likely to injure the left wrist, followed by lower back(2). Amateurs have most trouble with the elbow, which is the number one problem site for women and number two for men.
Four out of five golfers, at whatever level, will suffer low-back pain at some point in their lives. In recreational golfers this is usually down to sporadic play, poor swing mechanics or poor physical fitness.
The golf swing has evolved from a rhythmic flowing movement to one that generates increased power by using a larger shoulder turn and less hip turn. This modern swing technique, based on a tightly coiled body, enables maximum club-head acceleration, but at the cost of increased torque in the back(3). It leaves the back vulnerable at the top of the back-swing and during hyperextension in down-swing and follow-through.
In a comparative study of amateurs and professionals(4), the amateur players generated approximately 80% greater peak lateral bending and shear loads, and 50% more torque than the pros; and generated 90% of their peak muscle activity during a golf swing, against the professionals’ 80%. These inferior swing mechanics may predispose amateur players to muscle strains, facet disease or herniated discs in the spine.
Improved swing technique and physical fitness are the keys to avoiding back pain. Strength, flexibility and endurance all play a part: fatigue leads to uncoordinated muscle firing, resulting in injuries. Effective warm-ups, stretching and core-strengthening work will all lessen injury risk. Players with recurrent back pain should change to a smooth, flowing ‘classic’ swing – pelvis and shoulders rotate together and the forward heel lifts at the top of the back-swing – to reduce torque on their spines. In the follow-through, the player should learn to adopt a straight-up body position, avoiding hyperextension of the lumbar spine.
Most injuries occur in the left (leading) hand. During the golf swing of a right-handed golfer, the left wrist undergoes a smaller arc of dorsi- and palmar-flexion but a larger arc of ulnar and radial deviation than the right wrist(5). Overuse or poor wrist control during the swing can cause excessive movement leading to injury.
Fractures: These are un-common, but fractures of the hamate (the triangular bone in the hand sitting below the ring and little fingers) are a golfing speciality, accounting for a third of all hamate breaks(6). Despite this, damage to the hook of the hamate – caused by a direct blow from the handle of the golf club during a ‘fat shot’ – is often overlooked. Patients complain of vague, deep-seated pain or weak grip. There is local tenderness and pain to resisted flexion of the little finger. A carpal tunnel X-ray view or a CT scan is necessary to show the fracture radiographically. Chronic fractures may show rupture of flexor tendons to the ring and little fingers and neuropathy of the ulnar nerve(7).
Acute hook of hamate fractures rarely heal, so it is likely that painful bone fragments will need to be surgically excised, after which full activity is regained within four to six weeks.
To prevent this injury, the butt of the club should be of appropriate size and length, extending beyond the palm of the leading hand.
Tendon injuries: De Quervain’s Disease is a tenosynovitis of the abductor pollicis longus and extensor pollicis brevis (deep muscles of the forearm). This overuse injury is caused by a tight grip of the club and repeated ulnar deviation during the golf swing. Clinical findings include swelling and tenderness at the radial styloid and a positive Finkelstein test (ulnar deviation of the wrist with the thumb fully adducted causes marked pain).
Splints, taping and NSAIDs will relieve mild symptoms. Severe cases usually need corticosteroid injection. Where inflammation has resulted in thickening and stenosis of the fibro-osseous tunnel, surgery is indicated.
Flexor carpi ulnaris and flexor carpi radialis tendinitis are found in the right hand of the right-handed golfer, arising from the wider range of flexion and extension in the right (trailing) hand during the swing. Crepitus, localised swelling, tenderness and pain to resisted palmar flexion is present in both FCU and FCR tendinitis. Resisted pronation and radial deviation will cause pain in FCR tendinitis. Radiographs can show up calcific deposits in the tendon of FCU(8).
Splints (in neutral position), NSAIDs, temporary restriction of activity and corticosteroid injections are usually successful, but recalcitrant cases may require surgery.
Extensor carpi ulnaris tendinitis is characterised by tenderness over the ulnar aspect of the dorsal wrist. Symptoms are exacerbated by forced ulnar deviation and flexion of the wrist. Golfers with a tendency to ‘casting’ are at risk of developing this inflammation. It can usually be treated conservatively as with FCU/FCR above, plus modification of the swing.
Pain in the same region may alternatively indicate rupture of the ulnar septum with subluxation of ECU. In this case, the golfer usually complains of a painful snap as the subluxed tendon reduces during pronation of the forearm in the down-swing. Acute cases should be immobilised for six weeks. Chronic cases may respond to taping but will usually require reconstruction of the fibro-osseous tunnel.
Lateral epicondylitis (tennis elbow) is the most common elbow problem for golfers. It occurs on the outer aspect of the left elbow in the right-handed golfer. The motion of the left arm during the swing is similar to the backhand tennis stroke. It is the contraction of the left elbow extensor mass during impact, to maintain control of the club, that usually produces the injury. Clinically there is tenderness over the extensor mass 1-2cm distal to the lateral epicondyle. In severe cases resisted wrist extension or passive wrist flexion will aggravate the pain.
The most effective short-term treatment is corticosteroid injection, but to keep the condition at bay, patients will need to modify their activity(9). Once the acute symptoms have gone, patients should seek advice from a golf professional to reduce grip tension and swing errors (especially a flat swing plane). Clubs should have large grips, more flexible shafts (graphite or mechanically filtered steel) and heads with larger sweet spots to reduce vibration. A counterforce brace in the proximal forearm significantly reduces vibration and acceleration forces at the elbow(10). In recalcitrant cases, surgery is indicated.
Medial epicondylitis (golfer’s elbow) is an overuse syndrome involving the musculo-tendinous origins of the flexor pronator mass. Swing technique errors such as ‘hitting from the top’ can create excessive valgus stress on the elbow and lead to tension overload injury to the flexor pronator group. Patients describe aching pain on the inner side of the elbow, frequently radiating into the forearm. Patients may also complain of weakness of grip strength and pain to resisted wrist pronation and flexion. Associated ulnar nerve symptoms are common with this condition and are probably secondary to local inflammation, resulting in neuritis and entrapment.
Conservative treatment is similar to that for lateral epicondylitis. Once symptoms have improved, patients should follow a supervised rehab programme. Initially exercises are done with the elbow flexed, progressing into greater extension as symptoms improve. The goal is to achieve better levels of strength and endurance than pre-injury. And, as with tennis elbow, the golfer must improve their technique and equipment. Counterforce bracing is helpful.
Shoulder pain is less common in golf than in overhead sports but overuse injuries are still frequently seen in the lead arm. Watch out for referred shoulder pain arising from cervical spondylosis, cervical disc disease, diaphragmatic irritation and myocardial ischaemia.
The acromioclavicular joint is more commonly affected than the glenohumeral joint(11). At the top of the back-swing there is significant cross-body adduction with elevation of the left arm to 120 degrees. The cartilage separating the two articular surfaces of the acromioclavicular joint starts to deteriorate in the second decade of life. Repeated compression of a degenerated AC joint during the back-swing can lead to anterior shoulder pain. Treat initially by avoiding activities that worsen the pain, plus NSAIDs for pain relief. If pain persists, intra-articular steroid injection has shown to improve symptoms for at least 12 months(12).
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 back-swing with the club head at a 1 o’clock instead of a 3 o’clock position. Golfers with persistent symptoms and advanced arthritis may benefit from resection of the distal clavicle to unload the painful joint.
Rotator cuff impairment will often be the cause of shoulder pain in golfers from middle-age upwards(13). Indeed, the incidence of rotator cuff tears increases greatly after age 50(14). Electromyographic (EMG) studies of professional golfers have shown that the rotator cuff and especially the subscapularis muscle are highly active throughout the swing. Repeated stress to a degenerated tendon may lead to fibre failure, producing symptoms of bursitis or tendinitis; in cases of significant failure, the golfer will feel weakness elevating the shoulder. Partial rotator cuff tears are substantially more painful on resisted muscle action than full tears. Patients will usually complain of pain and tenderness in the anterolateral shoulder, crepitus and stiffness.
Selective isometric testing of muscle strength can help identify the tendon defect:
Patients with partial-thickness rotator cuff tears should be started on NSAIDs and an exercise regime including strengthening and stretching to restore normal flexibility. If non-operative treatment fails, patients may benefit from careful arthroscopic surgical debridment.
Symptomatic patients with full thickness tears or partial tears greater than 50% should be offered surgical repair.
Posterior instability: Younger competitive golfers may describe pain and a sense of instability during their golf swing. Some players even complain of an audible clunk when the left lead arm is fully adducted and internally rotated at the top of the back-swing or at the initiation of the forward-swing. It is possible that the unopposed rotation action of subscapularis muscle (which is highly active during the golf swing) may lead to posterior instability of the shoulder joint.
Physical examination typically reveals pain or symptoms of instability when the arm is flexed, adducted and internally rotated. With the arm abducted 90 degrees and in neutral rotation, axial load is applied to the elbow. Posterior subluxation with a click may be noted.
Most patients respond to an aggressive rehab programme of rotator cuff strengthening. If not, operative stabilisation, usually combined with subacromial decompression, is indicated(15).