With the Ryder Cup starting tomorrow and participation in Golf being at an all time high, BASEM Member & European Tour Performance Institute Research Fellow, Dr Patrick Robinson takes a look at “Golfing injuries – what are they and what should we do?”

Golf uptake has grown rapidly since the COVID-19 pandemic and there has been a significant growth in female participants. This may, in part, be secondary to the campaign for inclusivity and diversity in golf by governing bodies such as the R&A. With regards to golf as an activity, seminal work from Murray et al. has identified the health benefits of golf regardless of age. Playing golf helps players meet the World Health Organisation (WHO) recommendations for health enhancing physical activity as well improving mental health through social and outdoor activity.

As popularity continues to increase, there has been more engagement from clinicians and academics to explore factors related to illness and injury in golf in both recreational and elite players. Specific resources that may be of interest to the BASEM community includes:

• A dedicated E-edition of BJSM: https://bjsm.bmj.com/pages/e-edition-golfmedicine
• A golf focused edition of Aspetar Medical Journal: https://www.aspetar.com/Journal/articles.aspx?issueid=78&issuename=Targeted%20Topic%20-%20Sports%20Medicine%20in%20Golf

There has been recent biomechanical research on the demands of the golf swing but also articles exploring the rates, associations and burden of injuries in golfers, and specific injury sites (for example spine, and hand and wrist issues). There is now much greater understanding of the kinematics of the modern golf swing and the differences in injury patterns seen between recreational and professional golfers. Other factors may also include differences in club head speeds and playing volume (which is higher in professionals). The asymmetrical nature of the golf swing contributes to the asymmetrical injury patterns seen between the right and left sides of the body. McCarroll & Gioe reported 85% of upper limb injuries were lead sided (i.e. the left side in a right-handed golfer). In contrast, Dickenson et al. demonstrated professional golfers with hip pain have reported lower functional scores in the trail hip compared to the lead.

The most common anatomical regions of injuries seen in amateur golfers are the elbow, lower back and shoulder. However, in professional golfers it is hand/wrist, lower back and shoulder. There are three times as many injuries to the hand/wrist and lower back in professional golfers compared to recreational. Two thirds of injuries in professionals are in the lead hand/ wrist. Of these, over half are associated with the extensor carpi ulnaris (ECU) tendon. Common diagnoses in this group include; tenosynovitis, tendinopathy, subluxation and subsheath tears. The latter typically occur with acute trauma such as striking a tree root whereas the former are more likely to be seen in overuse-type patterns. It is helpful to consider wrist problems as categorised into three distinct areas; ulnar-sided, radial-sided and dorsal. Ulnar sided pathology as mentioned is typically related to the ECU tendon, however other causes include tears of the triangular fibrocartilage complex (TFCC) and ulno-carpal synovitis. Less common pathologies which are seen on the ulnar palmer side of the hand include hook of hamate fractures and ulnar neurovascular bundle compression. Almost all ulnar sided wrist pathology occurs in the lead wrist (i.e. the left wrist in a right-handed golfer). The pattern of injuries is likely related to the movement that occurs in the lead wrist which typically moves from a radial to ulnar deviated position throughout the golf swing.

Players with pain in the radial side of the wrist typically suffer from de Quervain’s tenosynovitis and intersection syndrome. Pathologies of the dorsum of the wrist can occur in either the lead or trail wrist. Pathologies most commonly seen are ganglions, dorsal synovitis and dorsal rim impaction syndrome. The latter is a condition caused by repetitive loaded extension of the wrist causing hypertrophic radiolunate synovitis.

Previous research from Robinson et al. has shown spine injuries in elite golfers typically occur in the lumbar and cervical regions. Sugaya et al. showed facet joint degeneration in symptomatic professional golfers was most common on the right side in right-handers. The repetitive, supranormal rotational and lateral bending forces that the intervertebral discs are subjected to during the golf swing can lead to traumatic discopathy which is thought to be the early cause of degeneration in the lumbar spine in golfers. In the cervical spine, the C4 to C6 region is most at risk of early degeneration. Non-degenerative injuries that can occur also include neuropathies secondary to disc prolapses, muscular spasms, stress fractures at the vertebral body or pars interarticularis and spondylolithesis.

It is also important to recognise golfing injuries in the context of other sports. The injury rates of recreational golfers per hour played are thought to be low compared to other sports and have been reported as 0.28-0.60 injuries per 1000 hours played. However, what is currently unknown is the burden of such injuries when they are sustained. We do however know from Gosheger et al. that the majority (83%) of injuries seen in recreational golfers are overuse in nature. All health professionals can play an important role in preventing and treating injuries in golf. These include:

• Physiotherapists
• Strength and conditioning
• Sports doctors
• Orthopaedic surgeons
• Imaging specialists
• Nutritionists

Much of the strength and conditioning performed by elite golfers is focussed correctly on the prevention of back, neck and hand/ wrist injuries. With regards to hand/wrist injuries, much like in other overhead sports such as baseball, clinicians hypothesise that injuries here can be caused by disorganised or compromised aspects of the kinetic chain elsewhere in the golf swing. Therefore, understanding the biomechanical demands of the swing including the correct sequencing of body elements is paramount to identify the origin of the problem with injured golfers. As clinicians, our understanding of golf injuries is improving. Similar to other sports, a holistic review of the player, their swing technique, practice and playing volumes, changes in volume and their strength and conditioning routines must be taken into consideration when assessing and treating any injury.

Dr Patrick Robinson MBChB, MRCSEd, MScR, MBA
European Tour Performance Institute Research Fellow
Trauma and Orthopaedic Surgery Registrar
University of Edinburgh