01 April 2019
Upper limb Injuries in golfers
Mr Al-Sabti, Upper Limb Specialist
Golf was first recorded in the eastern parts of Scotland in 1457 and is now enjoyed by over 60 million people around the world.
Most of the injuries in golf are due to over use however a number of acute injuries can occur. Injuries can affect the shoulders, elbows, wrists and hands. This can affect both amateur and professionals alike. Poor swinging can also contribute to injuries and other factors include hitting the ground or over swinging. As with all other sports, poor warm up can also cause injury.
In addition, falls on the golf course can be a cause of injury and being hit by a golf ball can cause serious facial injury.
The golf swing is a fundamental part of playing golf and this can cause injury during various phases of the golf swing. Injury can happen during the back swing, down swing, impact or the follow through. During the back swing the arms and shoulders are rotated around the axial skeleton and at the top of the swing, the wrists are in maximum radial deviation the forearm muscle is stretched. Repetition of this can cause injuries to the wrists, elbows and shoulders. During the down swing the weight will shift from the right side towards the left side for right handed golfers, the most active muscles in the upper limb will be the pectoralis major, the subscapularis and latissimus dorsi. Repetition of swinging can also lead to wrist, elbow or rotator cuff injury.
During the impact phase the majority of traumatic injuries can occur at that stage when the golfer strikes the turf or hits the ground unintentionally prior to hitting the ball.
During the follow through phase the body continues to rotate until facing the target and the left forearm supinates (rotates to the outside) as the right forearm pronates (rotates to the inside) and the weight shifts to almost all on the left foot.
The most common presentation is impingement syndrome or rotator cuff tears. Rotator cuff injuries are rather common in golfers in particular the subscapularis muscle which is active during the game. Both shoulders are vulnerable to injury during golf. Less common is the pectoralis major and the latissimus dorsi muscle can be injured.
While impingement syndrome can be treated with a steroid injection and physiotherapy with over 70% cure rate, rotator cuff tears will require surgical repair. This is usually carried out arthroscopically as a day case.
As part of the shoulder problem is the acromioclavicular joint which is a small joint at the top of the shoulder where repetitive movement can lead to degenerative changes and this results in pain and stiffness. Treatment will initially be a steroid injection and physiotherapy and occasionally an excision of the acromioclavicular joint may be required.
Shoulder instability is also noted particularly in young adults and a feeling of a pop is not unusual and the most common injury in such cases is either anterior instability leading to damage to the anterior glenoid or a SLAP (superior labral anterior to posterior) lesion. Such lesions are diagnosed clinically and radiologically with an MRI scan and will require surgical stabilisation which is usually carried out arthroscopically.
An interesting injury is weakness of the rhomboids and serratus anterior which can result in scapular lag. This subsequently leads to increased over all injury to the shoulder from the down swing all the way to follow through. Treatment usually includes physiotherapy to strengthen the muscles.
Shoulder injury prevention
Adequate warm up preparation is important and stretching prior to starting the game is also very important. Golfers should routinely strengthen their rotator cuff and scapular muscles.
Coaching and correct swing is important.
Elbow injuries are also common and the commonest known is golfer’s elbow which is pain on the inside of the elbows which is due to medial epicondylitis and inflammation at the common flexor origin of the muscles. Treatment of golfer’s elbow is initially steroid injection with physiotherapy and that usually works well and occasionally operative treatment is required which should only be considered after six months of unsuccessful conservative treatment and this is day case surgery which involves release of the tendons, removal of the diseased tissue and reattaching the tendon.
Lateral epicondylitis (tennis elbow) is also seen in golfers and can be due to vigorous contraction of the extensor carpi radialis brevis muscle as with gripping the club too tightly. This is due to degenerative changes and micro tears at the origin of the extensor carpi radialis brevis.
Treatment is very similar to medial epicondylitis with injection and physiotherapy as an initial step and persistent cases will require surgical release.
Wrist and Hand Injuries
Wrist and hand injury is very common in golfers affecting the flexor carpi ulnaris tendon which is the tendon on the inner aspect of the forearm towards the little finger side of the wrist. Tendinosis in that area is not unusual and similarly one can have this on the back of the wrist on the extensor carpi ulnaris which is another tendon on the dorsum of the wrist toward the little finger with instability of the tendon. Initial treatment includes rest and physiotherapy with gradual return to activity. Surgery is rarely indicated.
One of the commonest traumatic injuries in golf is a fracture of the hook of the hamate which is a small bone in the hand and wrist area and an injury to this will cause pain in the bone and this usually cannot be seen clearly on a plain x-ray and a CT scan may be required. Fracture of the hamate will require surgical fixation usually.
Another common complaint is carpal tunnel syndrome which is a common condition which affects the median as it goes into the wrist and gives rise to pins and needles. Initial treatment is rest and night splint and steroid injection is also helpful and lastly surgical release may be indicated.
I have seen a few patients who have golf related injuries and by that I mean falling from a golf cart sustaining an injury to the upper and lower limbs and I have seen patients hit by a golf ball.
Most injuries can be avoided by prevention measures such as warming up, conditioning and a proper swing mechanism.