Introduction Golf is a sport that is enjoyed by millions of people worldwide. Although most view golf as a low-impact low-risk sport, as many as 62% of golfers sustain golf-related injuries (Bulbulian, R., Ball, K., and Seaman, D., 2001). Common injuries include those to the shoulder, elbow, wrist, and low back. The most prevalent injury to both amateur and professional golfers is low back injury (Bulbulian, R., et al., 2001). It is thought to be the result of repetitive swing motion and overuse in professional golfers, while amateur golfers tend to have low back pain as a result of poor swing mechanics, poor physical conditioning, and excessive practice (Horton, J., Lindsay, D., and Macintosh, B., 2001). In general, amateur golfers are injured less frequently than professional golfers (Gosheger, G., Liem, D., Ludwig, K., Greshake,O., and Winkelmann, W., 2003). The Golf Swing The golf swing plays an important role in low back injury due to the large stress loads it places on the lower back. There are five stages of a golf swing. These stages are: set-up, backswing, transition, downswing, and follow-through (Fleisig, G., 1994). The set-up is the first stage of the golf swing and is an important part for every golfer. It consists of creating the proper grip and body positioning. This includes an even grip distribution between both hands and a proper angle of the golf club to the ground. The golfer should also be lined up properly with the ball, which means that the ball should be approximately 80% of the distance from the back foot to the front foot (Fleisig, G., 1994). Once the set-up has been completed, the golfer addresses the ball to begin the backswing. As the golfer moves the club back in a clockwise direction, a torsional force is created. This force is the result of an anterior shear force created by the right foot and a posterior shear force created by the left foot (right-handed golfers). Together, these forces produce a rotation that begins at the golfer’s knees and travels up to the hips, lumbar spine, and cervical spine. This torsional force may put repeated stress on the golfer creating low back pain (Fleisig, G., 1994). The third stage of the golf swing occurs as the golfer begins to shift his or her weight back to the left foot while the club is still completing the backswing. This stage is called the transition stage. It occurs until the club has stopped moving back in a clockwise direction (Fleisig, G., 1994). As the transition stage is completed, the golfer begins the downswing. This is the phase in which the majority of golf-related injuries occur. During the downswing the golfer continues to transfer weight back to the left foot while moving his or her hips toward the hole. The shear forces created from this movement are reversed from the backswing resulting in a counterclockwise torsional force of the upper extremities. This force extends to the club allowing the head of the club to attain a high velocity at impact (Fleisig, G., 1994). During this downswing phase of the golf swing, there are notable differences in the form of amateur golfers and professional golfers. This is seen in the degree of bend to the right side. It has been found that amateur golfers reach a lesser right side bend than do professional golfers. This is thought to be the result of increased movement of the hips toward the target (McTeigue, M., Lamb, S., Mottram, R., and Pirozzolo, F., 1994). Once impact occurs, the downswing is complete and the golfer continues the swing with the follow-through. The follow-through phase allows for deceleration without putting extra stress or strain on the muscles. In this stage of the modern golf swing, the golfer finishes in a reverse “C” position. This reverse “C” position may cause the golfer to hyperextend and is the source of many low back injuries (Fleisig, G., 1994). These five stages of the golf swing are the same for both the classic and modern swings. However, there are some differences between the two swings that may explain the increased risk of low back injury with the modern swing. The main differences are noted in the backswing and on follow-through. With the classic swing, there is a flatter swing plane compared to the modern swing. The classic swing also has a large turn of both the shoulders and the hips, while the modern swing produces a large shoulder rotation with a restricted hip rotation. This coiled modern backswing produces greater power and higher club head acceleration (Hosea, T.M., Gatt, C.J., Gertner, E., 1994). In addition to these differences in the backswing, there are also differences in the follow-through, most notably in the final ending position of the golfer. As described previously, the modern swing has a reverse “C” ending position that requires the golfer to arch his or her back and possibly hyperextend. In contrast, the classic swing has an ending position that produces less strain on the lower back. The ending position is a more vertical “I” position, which allows a more relaxed finish to the golf swing (Hosea, T.M., Gatt, C.J., Gertner, E., 1994). The phases of the modern golf swing that put the golfer at the most risk for injury are the top of the backswing, the uncoiling of the downswing, and the hyperextension of the follow-through. These are the points in the golf swing where the forces placed on the spine are at their greatest causing the spine to be most susceptible to injury (Grimshaw, P., Giles, A., Tong, R., and Grimmer, K., 2002). Mechanism of Injury There are four main forces exerted on the spine during the golf swing. The three axial forces are called the shear force, compression force, and lateral bending force. The fourth force is a rotational force referred to as torque (Hosea, T., Gatt, C., and Gertner, E., 1994). The shear force is directed from anterior to posterior, while the compression force travels in the cranial-caudal direction. The lateral bending force is directed lateral to lateral. In contrast, the torsional force is the result of twisting of the vertebral segments during the swing (Hosea, T., Gatt, C.J., and Gertner, E., 1994). The combination of these forces within the golf swing place a total compressive load on the spine that is eight times the golfer’s body mass (Lindsay, D. and Horton, J., 2000). These forces play a major role in the creation of low back pain in golfers. The combination of torsional, shear, and lateral forces cause a load that, when combined with swing repetition can cause or exacerbate low back pain. This injury to the back is due to the deterioration of ligaments and fibrous tissue surrounding the lumbar spine as a result of these repeated forces placed on the back (Grimshaw, P. and Burden, P., 2000). This deterioration of the surrounding spinal structures occurs over time as a result of overuse of these back muscles and ligament attachments (Bulbulian, R., et al., 2001). The repetitive motion of the asymmetric golf swing may also lead to disc failure and facet joint injury. These injuries are the result of the torsional forces placed on the spine, as well as the bending loads on the joints (Bulbulian, R., et al., 2001). The combination of these two forces, the lumbar side bend angle and the axial rotation velocity, are known as the “crunch factor.” The crunch factor occurs during the impact phase of the golf swing. Golfers with an increased crunch factor put increased force on their lumbar spine causing more damage to this area over time (Lindsay, D. and Horton, J., 2000). While overuse of this asymmetric modern swing is the most common cause of low back pain in professional golfers, low back pain in amateurs is attributed to poor swing mechanics, excess practice, and poor physical conditioning (Horton, J., Lindsay, D., and Macintosh, B., 2001). The poor swing mechanics that amateur golfers acquire create an increased torsional force on their spine. This causes an increased risk of injury on their low back (Vad, V., Bhat, A., Basrai, D., Gebeh, A., Aspergren, D., and Andrews, J., 2004). In addition, poor flexibility of hip flexors and lumbar extensors, poor timing of muscle activity, and weak musculature can lead to low back pain (Grimshaw, P., Giles, A., et al., 2002). It has been found that trunk muscle deficiency results in an altered trunk movement pattern, which leads to decreased strength of the spine and decreased ability of the spine to withstand the repetitive stress of the golf swing (Horton, J., et al., 2001). The transversus abdominus muscle has shown to play a major role in spinal stability and may increase susceptibility to low back injury if weak (Grimshaw, P., Giles, A., et al., 2002). Not all golfers with back pain have weak musculature in their trunk. A study from 2001 showed that inappropriate muscle activation created abnormal stress on the spine causing an increase in low back pain and injury. Their testing showed that the magnitude of abdominal muscle activity was similar in both golfers with pain and golfers without pain. The major difference between these two groups was that those with low back pain had later activation of the lead external oblique, trail external oblique, and trail internal oblique (Horton, J., et al., 2001). Another study from 2002 found a relationship between positioning and flexibility during the golf swing and incidence of low back pain. This study found that golfers with low back pain address the ball with increased amount of spinal flexion, which puts greater strain on the intervertebral discs of the lumbar spine. They also found that those with low back pain had an increase in their left side bend during the backswing (right-handed golfers) with increased left side bend velocities. During their swing, these golfers with low back pain had rotation measurements that were much greater than the maximum rotation attained with a controlled speed. These golfers were hyper-rotating during their golf swing, putting a large amount of stress on their low back (Lindsay, D. and Horton, J., 2002). Diagnosis of Low Back Pain These mechanisms of injury lead to one of two main causes of golf-related back pain. These are spondylogenic and discogenic back pain. Spondylogenic back pain is a result of injury to the spinal column and its associated structures. It can be broken down into either osseous or soft tissue pain. Osseous pain originates from a change in the bone pathology of the vertebral column and sacroiliac joints while soft tissue pain originates from traumatic and degenerative changes in the surrounding muscles, ligaments, and fascia. This type of pain is most often described as a deep, achy pain that increases with movement (Brooks Armstrong, N., 1994). While spondylogenic pain originates in the vertebrae and surrounding structures, discogenic back pain originates from changes of the intervertebral discs. This pain may or may not be associated with signs and symptoms of sciatica. The pain from disc degeneration may or may not be referred to the legs and is never associated with signs of nerve root compromise. In contrast pain from disc rupture is always associated with signs of nerve root compromise and the presence of radicular pain with or without back pain. Disc rupture may occasionally show signs of nerve root conduction impairment. Discogenic pain with nerve root impingement (radicular pain) is most often described as lancinating pain with numbness and tingling extending down the legs (Brooks Armstrong, N., 1994). Once the signs and symptoms of back pain have been established, there are certain elements that should be included in the physical exam. The evaluator should first look at the patient’s posture and back topography to look for signs of scoliosis, kyphosis, or spondylolithesis. The second step is to have the patient point to the area that is most painful. Once this area is identified, it is time to check the patient’s range of motion and perform a neurological examination, including strength testing, deep tendon reflexes, and skin sensitivity. It is also important to obtain X-ray, MRI, CT, and Bone scans as they are important tests in the diagnosis of low back pain (Brooks Armstrong, N., 1994). Management and Intervention The management of low back pain includes medical treatment, physical therapy and manipulation, and modification of the golf swing. In extreme cases of low back pain surgical intervention may be indicated. These treatment methods may vary depending on if the pain is acute or chronic. Manipulation therapy results in temporary improvement for both acute and chronic cases of low back pain. Patients with acute back pain may benefit from a short period of rest with the use of NSAIDS and ice. Other medications that may be beneficial for these patients include analgesics, muscle relaxants, and trigger point injections with Novocain with or without cortisone (Brooks Armstrong, N., 1994). These acute pain patients should avoid physical therapy in the first 1-3 days as it may result in further inflammation and discomfort. As they begin their physical therapy, the therapy should use both heat application and active exercises to strengthen their back. The use of passive exercise is contraindicated in these patients as it may result in increased inflammation and the formation of scar tissue (Brooks Armstrong, N., 1994). Patients with chronic low back pain may find relief from the use of rest and ice for acute flares of their pain. Their treatment should focus on three main treatment goals: flattening of the lumbar curve, increase of muscle tone, and improvement of posture. Manipulation of soft tissue during physical therapy may help to break up adhesions created from the chronic low back pain (Brooks Armstrong, N., 1994). All patients with low back pain can benefit from a good exercise program. Goals of exercise include increased strength and stability of the lumbo-pelvic region and abdominal region, especially the oblique muscles, transversus abdominus muscle, and multifidus muscle. The transversus abdominus should be strengthened first as it is important in maintaining spinal stability, which will help diminish discomfort while progressing to other strengthening exercises (Grimshaw, P., Giles, A., et al., 2002). To strengthen the transversus abdominus, the golfer should lie on his or her back with the knees bent and perform light strengthening exercises. Once the golfer progresses to begin strengthening the multifidus, the exercises are performed in either the supine or prone position and consist of raising one arm with the opposite leg while keeping the back straight (Grimshaw, P., and Burden, P., 2000). Other exercises should focus on increasing range of motion and flexibility. The areas of importance are the back and lower extremity. The goal should be to improve lumbar and thoracic rotation, hip flexion, hamstring flexibility, and low back extensors (Grimshaw, P., Giles, A., et al., 2002). Hamstring flexibility is especially important in patients with discogenic low back pain (Brooks Armstrong, N., 1994). Another important exercise to assist the golfer to properly and safely transfer strength through the legs and body during the golf swing is an isometric trunk exercise called the “dead bug.” This exercise is performed while lying on the back with the knees flexed and feet on the ground with a small folded towel under the lower back. The golfer then contracts the abdominal muscles while pushing the lower back against the towel until the position is fairly comfortable and able to be maintained. At this point, the golfer lifts one leg, while keeping the back position constant, and then flexes and straightens the leg. The golfer alternates this move with each leg. As the golfer becomes stronger this position can be used for both arm and leg raises (Brooks Armstrong, N., 1994). In addition to these medical interventions, modification of the golf swing can play an important role in improving low back pain. These modifications in the swing all have the common goal of decreasing the amount of spinal rotation to put less stress on the spine (Lindsay, D. and Horton, J., 2002). One method of achieving less spinal rotation is by increasing the range of motion in the hips to decrease the difference in rotation between the hips and shoulders. By increasing the amount of hip rotation on the backswing and downswing, there is less shoulder-to-hip rotation and less torsional stress of the thoracic and lumbar spines. This change in the golf swing also decreases the total load on the lumbar spine, creating a lower risk of reinjury (Grimshaw, P. and Burden, P., 2000). A second method of decreasing the amount of spine rotation and torque on the lower back is by adopting a shorter backswing. A study from 2001 tested the effect of this modification on the outcome of the golf swing, as many golfers would rather risk injury than worsen their golf score. This study measured the club head velocity and stroke accuracy between the modern golf swing and a golf swing with a shorter backswing. The study found that there was no change in club head velocity or stroke accuracy and showed that the shorter backswing allowed for a more consistent stroke pattern. The only unfavorable outcome was seen in professionals, who showed increased variability in club head velocity with the modified backswing (Bulbulian, R., et al., 2001). The classic golf swing also exerts less torque on the low back. This swing creates less spine rotation by lifting the forward heel at the top of the backswing while rotating the pelvis and shoulders in unison. This places less stress on the low back, allowing the golfer to continue their sport with less pain (Parziale, J.R., 2002). Risk Factors Although it is important to understand the identification and treatment of the golfer’s low back pain or injury, it is also important to understand the type of golfer that is at risk for injury. Knowing those at risk can help identify and even prevent the low back injury. As discussed in the mechanism of injury, golfers with decreased fitness levels have an increased risk of developing low back pain. This decreased fitness level is associated with decreased trunk muscle strength and increased incidence of chronic low back pain. It has been shown that persons who take up golf after a long period (>5 years) of physical inactivity, both at work and in leisure, have a much greater risk of developing low back pain than those who are physically active (Burdorf, A., Van Der Steenhoven, G., and Tromp-Klaren, E., 1996). Other risk factors that are more easily measured include persons with limited lumbar spine extension, limited lead hip internal rotation, and increased FABEREs distance of the lead hip. FABEREs distance is measured with the patient in the supine position with the hip flexed, abducted, and externally rotated. The patient rests the ipsilateral ankle on the contralateral knee while the examiner measures the distance from the knee to the horizontal table. In a 2004 study, the golfers without pain were found to have a FABEREs distance of 9.3 +/- 1.5 cm, while those with pain were found to have a distance of 16.8 +/- 1.3 cm (Vad, V., et al., 2004). Prevention While understanding the risk factors is helpful for identifying low back pain in golfers, it is more helpful to teach the golfer ways to prevent injury or recurrence of injury. The most common routine seen in golfers without low back pain is a warm-up that lasts ten or more minutes before starting a round of golf. Another preventative method is to perform regular stretching exercises to help improve maximum trunk range of motion (Lindsay, D. and Horton, J., 2002). The focus of these exercises should be strengthening and flexibility rather than the golf swing itself (Bulbulian, R., et al., 2001). In addition to warm-up and stretching, back pain can be prevented by improving certain aspects of the golf swing. This includes improving address posture to attain the proper amount of trunk flexion (Lindsay, D. and Horton, J., 2002). This may be accomplished by making physical adjustments or even by adjusting the club’s shaft length. In a study focusing on the shaft length of putters, it was found that an increased shaft length lead to decreased trunk flexion resulting in decreased torque and muscle activation of the low back and decreased risk of injury (Gulgin, H.R., Armstrong, C.W., and Okuda, I., 2003). Low back pain can also be prevented by altering the backswing. By decreasing the amount of backswing rotation, there is less stress and strain placed on the trunk and spine. This will minimize the amount of lumbar and oblique muscle activation to decrease the risk of injury (Bulbulian, R., et al., 2001). It is also helpful to work on improving abdominal muscle function during this phase of the golf swing to create more spinal stability (Lindsay, D. and Horton, J., 2002). Conclusion In conclusion, golf is a sport that is enjoyed by persons of all physical abilities. It is associated with certain risk factors and mechanisms of injury. Most injuries are the result of the forces applied to the spine during the different phases of the golf swing. These injuries can be prevented or minimized by understanding how to strengthen and stabilize the muscles involved in the golf swing, in addition to improving flexibility. Adjusting the golf swing to a more classic approach has also shown to be helpful in preventing or reducing the risk of injury or re-injury to the lower back. By understanding the appropriate interventions, golf can be resumed after injury without implications on the health of the golfer. References 1. Brooks Armstrong, N. (1994). Back Pain: Diagnosis and Treatment. In Stover, C.N., McCarroll, J.R., and Mallon, W.J. (Eds.), Feeling up to Par: Medicine from Tee to Green (pp.109-125). Philadelphia: F.A. Davis Company. 2. Bulbulian, R., Ball, K., and Seaman, D. (2001). The Short Golf Backswing: Effects on Performance and Spinal Health Implications. Journal of Manipulative and Physiological Therapeutics, 24(9), 569-575. 3. Burdorf, A., Van Der Steenhoven, G., and Tromp-Klaren, E. (1996). A One-Year Prospective Study on Back Pain Among Novice Golfers. The American Journal of Sports Medicine, 24(5), 659-664. 4. Fleisig, G. (1994). The Biomechanics of Golf. In Stover, C.N., McCarroll, J.R., and Mallon, W.J. (Eds.), Feeling up to Par: Medicine from Tee to Green (pp.17-26). Philadelphia: F.A. Davis Company. 5. Gosheger, G., Liem, D., Ludwig, K., Greshake, O., and Winkelmann, W. (2003). Injuries and Overuse Syndromes in Golf. The American Journal of Sports Medicine, 31(3), 438-443. 6. Grimshaw, P. and Burden, P. (2000). Case report: reduction of low back pain in a professional golfer. Medicine and Science in Sports and Exercise, 32(10), 1667-1673. 7. Grimshaw, P., Giles, A., Tong, R., and Grimmer, K. (2002). Lower Back and Elbow Injuries in Golf. Sports Medicine, 32(10), 655-666. 8. Gulgin, H.R., Armstrong, C.W., and Okuda, I. (2003). Influence of shaft length on low back torque and levels of muscle activation in putting. Medicine and Science in Sports and Exercise, 35(5), (Supplement 1) S27. 9. Horton, J., Lindsay, D., and Macintosh, B. (2001). Abdominal muscle activation of elite male golfers with chronic low back pain. Medicine and Science in Sports and Medicine, 33(10), 1647-1654. 10. Hosea, T.M., Gatt, C.J., and Gertner, E. (1994). Biomechanical Analysis of the Golfer’s Back. In Stover, C.N., McCarroll, J.R., and Mallon, W.J. (Eds.), Feeling up to Par: Medicine from Tee to Green (pp.97-108). Philadelphia: F.A. Davis Company. 11. Lindsay, D. and Horton, J. (2002). Comparison of spine motion in elite golfers with and without low back pain. Journal of Sports Sciences, 20(8), 599-605. 12. McTeigue, M., Lamg, S., Mottram, R., and Pirozzolo, F. (1994). Spine and hip motion analysis during the golf swing. In Cochran, A.J. (Ed.), Science and Golf II: Proceedings of the World Scientific Congress of Golf. London: E & FN Spon. 13. Parziale, J.R. (2002). Healthy Swing: A Golf Rehabilitation Model. American Journal of Physical Medicine and Rehabilitation, 81(7), 498-501. 14. Vad, V., Bhat, A., Basrai, D., Gebeh, A., Aspergren, D., and Andrews, J. (2004). Low Back Pain in Professional Golfers: The Role of Associated Hip and Low Back Range-of-Motion Deficits. The American Journal of Sports Medicine, 32(2), 494-497.
Provided by
