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Sports Med 2006; 36 (2): 171-187
R
EVIEW
A
RTICLE
0112-1642/06/0002-0171/$39.95/0
2006 Adis Data Information BV. All rights reserved.
Golf Injuries
A Review of the Literature
Andrew McHardy,1 Henry Pollard1 and Kehui Luo2
1 Macquarie Injury Management Group, Department of Health and Chiropractic, Macquarie
University, Sydney, New South Wales, Australia
2 Department of Statistics, Macquarie University, Sydney, New South Wales, Australia
Contents
Abstract ....................................................................................171
1. Epidemiological Studies ..................................................................174
1.1 Professional .........................................................................174
1.2 Amateur ............................................................................174
1.3 Methodological Analysis ..............................................................175
2. Specific Injury Sites .......................................................................175
2.1 Low Back Injuries .....................................................................175
2.2 Wrist/Hand Injuries ...................................................................178
2.3 Elbow Injuries ........................................................................180
2.4 Shoulder Injuries .....................................................................180
2.5 Knee Injuries .........................................................................182
3. Major Injury – Head and Eye Injuries ........................................................182
4. Other Injuries ............................................................................183
4.1 Stress Fractures ......................................................................184
5. Conclusions .............................................................................185
Golf is one of a few activities that people of all ages and skill level can play.
Abstract Injury as with all sports can occur. The low back is the most common injury
sustained whilst playing golf, and the dynamic action of the golf swing is a major
contributing factor to injury. The golf swing is a complex movement that utilises
the whole body in a coordinated fashion and when repeated frequently can result
in injury. Injury can be overuse or traumatic in nature. Overuse injuries
predominate in the professional golfer, and amateur golfer injury tends to occur
secondary to an incorrect golf swing. Upper limb injuries are also common due to
their role in linking the fast moving golf club with the power-generating torso.
Fortunately, injury from a club or ball strike is rare. More common are the overuse
injuries associated with the back, neck and shoulder. Most golf injury data have
been collected retrospectively and further epidemiological study of a prospective
nature is required to determine injury incidence and factor relating to the onset of
injury.
Golf is a popular sport played worldwide by that there are no sex, skill or age limits to participa-
people of all ages and skill level. Part of its appeal is tion. Golf participation rates are spread across all
172 McHardy et al.
age ranges but are high in the older age brackets. A good understanding of golf injuries requires
This is partly due to the fact that the older/retired the practitioner to consider the quality, quantity and
population have more leisure time to pursue activi- type of golf swing employed by the golfer. Skill
ties and golf is low impact with a general aerobic level is determined by how many shots/strokes they
component, which makes it a perfect recommenda- have to complete a game (or round) of golf of 18
tion for medical practitioners wanting their patients holes. Par is the score that a professional would be
to exercise. Golf is a popular option as it also expected to score on a championship golf course.
provides social interaction and can be played at all The par for such a course is generally 72. For
skill levels due to its handicap system. For many example, a person who scored 90 strokes on a par 72
people who play ball sports, age results in decreased course, would be rated at 18 over par. If this score
fitness, speed and endurance and they are unable to was averaged over several performances, a handicap
participate at the levels conducive to competition. of 18 would apply. The lower the handicap, the more
For those people who like to remain active and skilful the golfer.
competitive, golf is a popular option. The average Australian golf club handicap is 18.1
Although they are uncommon, injuries incurred in males and 27.5 in females.[5] A gradual increase in
while playing golf are an increasing problem. Con- handicaps as age increases, with the 18–30 year age
sidering the popularity of the game and the market group being the peak age group for handicap players
that is golf (equipment, tuition, sponsorship), there in Australia with an average handicap of 14.4 for
have been only a small number of studies on golf males and 22.5 for females (see table I).[5] In the US,
injuries. Indeed, most of the injury rates in golfers the average handicap is 16.1 for men and 29.2 for
cited, review research produced 10–25 years ago. women.[6,7] The American data also reveal that for
This observation is also made by the most recent men, the middle quartile (25–75%) for golf handi-
study by Gosheger et al.,[1] who reported that most caps range from 10 to 20,[6] with the females range
of our understanding of golf injuries relies on two being 22–35.[7]
publications produced >10 years ago, McCarroll et In Australia, golf participation rates by civilian
al.[2] in 1990, Batt[3] in 1992 and one produced >20 persons >18 years of age during a 12-month period
years ago by McCarroll and Gioe.[4] This article prior to census interview in 1999–2000 was 1.1
examines the available literature on the epidemiolo- million, a figure that corresponds to a participation
gy of golf injuries and investigates the differences in rate of 7.5%.[14] This rate equated to golf being the
injury location and mechanism seen in professional fourth most popular non-organised activity behind
golfers when compared with amateur golfers. The walking, swimming, aerobics/fitness and the second
article determines areas of common injuries and most common organised activity behind aerobics/
where possible presents the likely mechanism of the fitness.[14] In males, golf was the most popular sport
common injuries that occur in golfers. accounting for 890 300 participants (12.4% of the
The investigators conducted a MEDLINE, population), while there were 193 300 female par-
SportDiscus and EMBASE search with the key ticipants (2.6% of the population).[14] Of golf partici-
words ‘golf’ and ‘injury’ between the years 1965 to pation, 50.3% was classed as organised (involving
present. The results were collated and those studies some form of club organisation), while the highest
that examined injuries associated with playing golf participation rate for golf was recorded in the 55–64
were included. Initially there were 206 relevant pa- year age group (9.3% or 176 000 people), followed
pers included in the search criteria. On analysis of by those aged 45–54 years (8.8% or 233 700).[14] In
reference lists of selected papers, a number of refer- Australia (with a population of approximately 20
ences were from conference proceedings and these million), there were 477 084 registered golfers in
papers were included. In total, >250 papers relating 2002.[5] In New Zealand, with a population of ap-
to golf injures were collated and examined. proximately 4 million, there are approximately
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 173
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Table I. Overview of golf injury epidemiology studies
Study Source of data No. of respondents Most common
injuries mechanism/comments
McCarroll et al.[2] Amateur 1144 Males: lower back, elbow, wrist/hand Excessive play/practise, poor swing mechanics,
(942 males; 202 females) Females: elbow, lower back, shoulder hitting the ground, 50% of all injuries occurred at
impact
Batt[3] Amateur 193 Males: wrist, back Incorrect swing/miss-hit (affecting wrist back more
(164 males; 29 females) Females: elbow commonly), overuse type injuries (wrist was the
most common)
A player that had a low handicap <10 was more
likely to injure their wrist or elbow or experience a
muscular injury than those with a higher handicap
Nicholas et al.[8] Amateur 368 47.6% had been struck by a golf ball in Most serious injury being struck by a golf ball
the lower extremity followed by the trunk Contusion followed by concussion and fracture
and upper extremity injury sites was the most common sequelae
Theriault et al.[9] 528 golfers (347 females; Upper limb (42.4%), spine (39.7%), Technical injury (53.9%), overexertion of the trunk
181 females) lower limb (17.9%) during the swing (30.8%), overuse (14.1%)
Burdorf et al.[10] Back pain in 196 Baseline survey: life-long cumulative Those that were athletes had increased odds ratio
beginner males incidence of back pain was 63% of 2.1 to previous back pain compared with non-
28% had a history of back pain within athletes
1mo prior to answering the survey
Gosheger et al.[1] Amateur and 643 amateurs (70.9% male) Professionals: back, wrist, shoulder >4 of 5 injuries were attributed to overuse,
professional 60 professionals (90% Amateurs: elbow, back, shoulder particularly in the back, shoulder, knee and elbow
golfers male)
McCarroll and Gioe[4] Professional 226 Male: low back, left wrist, left shoulder (in
(127 males; 99 females) right-handed golfers)
Female: left wrist, low back, left hand
Overall: left wrist, low back
Sugaya et al.[11] Low back pain 283 golfers (regular tour Low back, followed by neck/high back 72% experienced injuries that caused them to
amongst elite/ males 115, senior tour and elbow and shoulder equally miss a tournament or perform at a lower level,
professional males 55, and 113 female mostly due to back and upper extremity injuries
tour, 45%) Low back pain location: 51% right-side pain, 28%
left side and 21% central
McNicholas et al.[12] Sports medicine 286 The most common site of injury was 25% female, 27% were <40y of age, 8% were
clinics data reported as the upper limb, followed by >60y
collection the trunk and the knee Nearly 90% were recreational golfers
Of the upper limb injuries, lateral epicondylitis was
the most common problem area, followed by
shoulder impingement and medial epicondylitis
Finch et al.[13] Sports medicine 34 Lower back, elbow and knee Overuse, a twist or rotational component of the
clinics and swing, which the authors attributed to poor swing
emergency mechanics and an aggravation of previous injury
departments Elbow injury was due to overuse (two-thirds),
miss-hits (one-third)
174 McHardy et al.
Table II. Incidence of injury for the most common locations for various groups of golfers[1-4,8-13]
Area Amateur (%) Professional (%) Male (%) Female (%)
Low back 15–34 22–24 25–36 22–27
Wrist 13–20 20–27 18–28 12–36
Elbow 25–33 7–10 8–33 6–50
138 000 registered golfers.[15] In both countries, to itive) of practising the golf swing, followed by hit-
be a registered golfer, you must be a member at any ting an object other than the ball while swinging the
one of the Golf Clubs affiliated to the Australian golf club or a golf swing injury that occurred during
Golf Union or NZ Golf, respectively. The number of competition.[4]
registered golfers in Europe is 3 741 680 as at Professionals are susceptible to overuse injuries
March 2003,[16] while in the US, the number of due to the amount of practise they perform in their
golfers with a handicap is 4.5 million and the num- pursuit of excellence.[4] Even though professionals
ber of golfers >18 years who have played in the last are adapted to withstand a higher frequency/intensi-
12 months is 26.2 million.[17] ty of play, excessive play can promote overuse
injury. As the professional depends on earning a
1. Epidemiological Studies living from golf, they often continue with practise
even though they have an injury. As a result, the
A number of studies have been conducted that professional golfer is more likely to aggravate an
examine the occurrence of injuries in golf- injury condition more than the amateur golfer.
ers.[1-4,8-13,18] Both amateur[1-3,8-10,12,13,18] and elite/
professional golfers,[1,4,11] as well as male and fe- 1.2 Amateur
male player groups,[1-4,8-13] have been the focus of
these studies. A summary of epidemiology studies is In amateur golfers, common injury sites include
shown in table I. Researchers have used varying the low back, wrist, the elbow and the shoulder.
methodological procedures to report these statistics. Several researchers[2,13] reported the lower back as
Research data have been collected from the distribu- the most common injury site in males while Batt[3]
tion of surveys by mail,[2-4,8-11] direct interview of reported the wrist as the most common site injured.
players,[1] and data collection at hospitals and sports Theriault et al.[9] and McNicholas et al.[12] did not
medicine clinics.[12,13] Common injuries of the dif- split the upper limb into regions and hence found it
ferent sub-groups of golfers is shown in table II. the most common injury site. Elbow injuries, partic-
ularly in females, were a common injury site in
1.1 Professional golfers.[1-4]
In professional golfers, the most common site of Most of the golf-related injuries seen at hospital
injury for males was the low back, followed by the emergency departments involved the head,[18] while
left wrist and left shoulder (in right handed golf- Nicholas et al.[8] reported that being struck by a golf
ers).[1,4] ball occurred mostly in the lower extremity, with the
In the female professional, the most common site trunk and then the upper extremity less likely. In the
of injury was the left wrist, followed by the low back case of elbow injuries, most injuries that occurred
and left hand.[4] Overall, the two most common were diagnosed as lateral epicondylitis (‘tennis el-
injury sites in professionals was the left wrist closely bow’), particularly in the left elbow (non-dominant)
followed by the low back,[4] although Sugaya et of the right-handed golfer.[2,12,13] The most common
al.[11] found that the lower back followed by the neck mechanisms of injury in golfers are overuse (too
were the two most common injury sites. The most much play/practise), poor biomechanics of the
common mechanism of injury for professional golf- swing and hitting the ground of an object during the
ers (male and female) was the high frequency (repet- swing.[1-3,13] Catastrophic injury may occur as a con-
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 175
sequence of being struck by either a golf club or golf has only been 3–5 years, injuries can be more readi-
ball, although this is rare.[12,18] Excessive play/prac- ly recalled than if the subject has been playing golf
tise was reported to be the most common source for for >40 years. Gosheger et al.[1] has also noted this
injury to occur.[2,13] Incorrect swing/miss-hit (poor potential limitation of the golf literature.
swing mechanics) was reported by Batt[3] to be the The data produced by a study need to be large
most common mechanism of injury in which the enough to be able to draw conclusions. The more
wrist or back were the most likely to be injured. subjects in a study sample, the more representative
Theriault et al.[9] reported technical injury (53.9%) is that study sample of the population it is trying to
as the most likely reason to sustain an injury (most represent.[23] Sample sizes ranging from 34 (8 in
likely relates to poor mechanics). Being hit by a golf females[3]) to 1144 participants appear in the golf
ball was the most likely reason for an adult to be literature.[2]
admitted to hospital for a golf-related injury, while The above data demonstrate that there is a pauci-
for a child it was being struck by a golf club. Adult ty of high-quality, large studies examining the epi-
injuries were most likely to occur on a golf course, demiology of golf injuries. Further studies into the
whilst a child was most likely to be injured in the epidemiology of golf injuries require redress of
home environment.[18] methodological issues identified above that affect
the accuracy of collected data. The next discussion
will present a closer look at the data of specific
1.3 Methodological Analysis
injury sites.
In reviewing the data produced by these studies, a 2. Specific Injury Sites
number of methodological issues need to be consid-
ered. The response rate of surveys should be report-
ed or otherwise evaluated, as the response rate indi- 2.1 Low Back Injuries
cates how representative the data collected is of the The low back has been reported as being the most
whole golfing population. The higher the response common site of injury in a golfer,[2,4,11,13] accounting
rate, the more representative the data is of the golf- for 23.7–34.5% of all injuries. Due to the mechanics
ing population.[19] Response rates of the retrospec- of the swing, the low back is subject to large ranges
tive studies reviewed ranged from 20.6% to of motions and forces.[24] The forces that occur as a
57%[2-4,8,11] and 78.4% in prospective studies.[10] The result of the mechanics of the golf swing may be
type of data the survey is trying to obtain also categorised as:
reflects on the results produced. Retrospective stud- •downward compression
ies are easier to produce as they are examining what •side to side bending
has occurred in the past, while prospective studies •sliding, back to front shearing.[25]
involve looking at what happens from a set of time
Peak compressive load during the golf swing has
forward for a defined period of time, a year for
been shown to be 8-times bodyweight (compared
example.[20] This prospective type of study is harder
with rowing [7-times] or jogging [3-times]).[25]
to institute because of increased costs and time spent
on the study, as well as having problems associated In an analysis of the differences in the golf swing
with dropout rates, but produces stronger conclu- of amateurs and professionals, research has found
sions.[21] The golf literature is primarily retrospec- that amateurs reach 90% peak muscle activity com-
tive in nature.[2-4,8,11] Many of the retrospective stud- pared with 80% in professionals and the lumbar
ies ask the participant about injuries sustained in spine is under more load in amateurs.[25] The study
their career, which gives rise to the phenomenon of found that both groups of players had the same
recall bias. Recall bias is the inaccurate reporting of compression loads, but amateurs incurred 80% more
data that results from alteration in recollection of lateral bending and peak shear loads and 50% more
events that occurred in the past.[22] If a golfing career torque than their professional counterparts.[25] Anec-
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
176 McHardy et al.
dotal evidence from personal observations/exper- bined with the large forces produced in the lower
iences of the authors suggests that these characteris- back, this may result in the increased risk of strains,
tics are mainly due to the amateur player trying to hit disc herniation and facet arthropathy.[26]
the ball further by swinging harder, particularly with A number of swing types are common in golf. A
the driver (the club used to hit the ball the furthest basic understanding of the golf swing types is re-
distance). The professional player has practised quired for practitioners to be able to understand how
enough to produce a nearly identical swing each golf swing-related injuries may occur. There is the
time they play a full shot. As a result of this practise, classic golf swing that was popular in the early/mid
their swing is grooved and becomes second nature part of the twentieth century and there is the modern
and thus efficient to them. In most cases, amateurs swing that Jack Nicklaus introduced in the 1960s.
lack this desirable feature and this may predispose to The modern swing generated more power to the ball,
injury as poor swing mechanics increase the forces increasing the distance the ball travelled. It also
generated by the golf swing. produced higher shots that stopped shortly after
The golf swing is a complicated action with landing, which was helpful in shots to the green. The
intrinsic and extrinsic factors affecting the golfer’s main differences in the swings was the large pelvic
ability to hit the ball with power and accuracy. As a and shoulder rotation in the classic backswing as
result of this complexity, injuries can occur. If the opposed to the limited pelvic rotation compared
swing is not as free flowing and as efficient as with shoulder rotation in the modern backswing
possible, injuries are likely to occur. (figure 1).[27] This differential in rotation generates a
coiling effect of the trunk that helps with power
The golf swing involves a large range of motion
development. The follow-through position was also
and is repetitive, especially during practise. Com-
ab
Fi
g
. 1. Backswin
g
. Modern
(
a
)
compared with classic
(
b
)
.
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 177
ab
Fi
g
. 2. Follow-throu
g
h. Modern
(
a
)
compared with classic
(
b
)
.
different with a relatively neutral spinal position and have 0.19 relative risk. This raises the question of
forwards body momentum in the classic swing as whether golf has a protective mechanism to discal
opposed to the hyperextended spine and upwards problems compared with not playing the game.[30]
body momentum on the modern swing (figure 2). However, golfers with discal-associated low back
This reverse ‘c’ position of the follow-through in the pain would not play golf due to the belief that the
modern swing (producing hyperextension of the golf swing will aggravate their condition. Thus,
lumbar spine and right lateral flexion) has the poten- there may be some selection bias in this finding.
tial to result in facet irritation if constantly repeat- Sugaya et al.[11] examined the prevalence of low
ed.[28] A third swing is gaining popularity, which back pain amongst elite/professional golfers at three
combines elements of both swing types. The hybrid major golf tournaments and final qualifying test. Of
swing utilises the backswing of the modern swing the 283 golfers that responded (only one player was
with its power generating potential and the follow- left handed and excluded from the study for consis-
through of the classic swing with its neutral spine. tency purposes), the most common injury site was
This swing is thought to generate similar power to low back, followed by neck/high back and elbow
the modern swing, without the hyperextended spine and shoulder equally. Of these golfers, 72% exper-
(and potential for injury) of the modern swing.[29] ienced injuries that caused them to miss a tourna-
ment or perform at a lower level. An injury to the
Refuting the data that show that golf may in-
low back was responsible for missed play 55% of
crease the likelihood of experiencing discal
the time. Of the players who experienced low back
problems is research that showed golfers had 0.59
pain and recorded pain location, 51% had right-side
relative risk of herniated disc to those that do not
pain, 28% left side and 21% central. An important
play sport, while those that play >2 times per week
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
178 McHardy et al.
statistical correlation between right-sided back pain women who were previously diagnosed, or subse-
and the follow-through was found when analysing quently diagnosed, with osteoporosis. This shows
where the pain occurred during the swing (p < 0.05). that the most common site of stress in the back
This study also took radiographs of 16 players (there appears to occur around the thoracolumbar region, a
was no selection criteria, which raises the question transition segment of the spinal column. The ques-
of selection bias) with low back pain and found that tion that needs to be asked is “If there was no
compared with age-matched controls, golfers had osteoporosis, would the compression fractures have
statistically more osteophytic formation at L3/4 (p < occurred?”. Further research into this area is needed.
0.01), and in total (p < 0.01). They also found that
facet changes were statistically different overall (p < 2.2 Wrist/Hand Injuries
0.01) and at L4/5 (p < 0.01) and L3/4 (p < 0.05).
In another study, Burdorf et al.[10] conducted a Along with the low back, the wrist is the most
1-year prospective study on back pain amongst common site of injury in golfers.[3,4] The wrist pro-
males taking up golf. 221 completed the first survey vides the anchor point of the club to the arms and
(88% response) with 89% completing the follow-up body during the swing. As such, the wrist moves
survey (196). The baseline survey showed the life- through a relative wide range of motion during the
long cumulative incidence of back pain as 63%, with swing.[33,34] Motions include flexion, extension, ra-
a 28% reporting a history of back pain within the 1 dial and ulnar deviation, with pronation and supina-
month prior to the completion of the survey. Those tion of the forearms also being a feature of the golf
that were athletes had an odds ratio of 2.1 for swing.
previous back pain compared with non-athletes. The most common injury mechanism in wrist
During the 12-month prospective period of the injuries occurs as a result of hitting an object other
study, 8% reported a first time occurrence of back than the ball. These injuries are usually of the acute
pain and 45% reported the recurrence of back pain. nature. The injury is the result of a sudden decrease
Only six subjects attributed golf to this recurrence. in movement of the accelerating hands and wrist at
Compared with those who only played golf, those impact that can produce enough forces to disrupt
who also played one other sport had a risk of 1.4 to tissue structures. Injuries of this nature tend to occur
recurrence of back pain at the hand and wrist, but can also occur in the
The rate of back injury in junior golfers has been elbow. Muscular strains and ligamentous strains are
investigated. This study found that the incidence of common, but fractures of the hook of hamate may
back pain in golfers was not different to age- also occur due to this mechanism. Hitting off stones
matched controls when compared with others stud- of hard ground may also produce similar injuries.
ies in similar aged children.[31] However, in those The hitting of a ‘fat’ shot, i.e. hitting the ground first
junior golfers with back pain, most pain was report- during the process of hitting the ball is another
ed to occur in the right lumbar region. This figure possible source of this mechanism of injury, which
correlated to right side lumbar pain in 93% of right- tends to occur mainly in the amateur ranks. The
handed players. This right side predominant pain professional golfer can sustain a similar type of
location in right-handed golfers is similar to that injury in slightly different circumstances. In major
found in professional (adult) golfers described by tournaments, particularly at the links courses of the
Sugaya et al.[11] UK, the rough tends to be quite thick and long. As a
Compression fractures in older females during result, if a ball is nestled in the rough, a lot of force is
the golf swing have been reported in the litera- required just to get the ball back onto the fairway.
ture.[32] The compression fracture sites were con- Combine this with the fact that long strands of grass
fined to the lower thoracic and upper lumbar verte- tend to wrap themselves around the hosel and shaft
brae, and were reported in healthy postmenopausal of the club during the downswing, which has the
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 179
potential to place more force on the upper limb and mechanism, which results from either a sudden in-
cause injury. crease in the volume of practise or the changing of
the grip (causing increased loading on an unaccus-
Other injury mechanisms that involve the wrist tomed part of the wrist), and subsequent practise.[42]
are overuse related, often due to the repetitive nature It is gradual in onset, persistent in nature and contin-
of practise, or from changes to the swing that result ues until the aggravating factor(s) is stopped or
in stress to structures unaccustomed to the type of rested until allowed to heal.[35,41,42]
stress the golf swing produces. A study of the Spain
National Insurance Scheme for sportspeople found Large forces are produced in the golf swing just
that 10% of golfers experienced a wrist injury.[35] prior to impact, particularly in the flexor tendons. In
Causes of wrist injury were reported as overuse or the case of right-handed golfers, the flexor carpi
sudden change in swing.[35] This survey found that ulnaris of the right wrist is vulnerable to injury from
wrist injuries from golf may be categorised as either microtrauma due to these forces, particularly when
articular (mostly occurring via fractures, particularly golfers take divots (hit the ground). There is a slight
the hook of hamate) or extra-articular most often increase in resistance experienced as the club en-
tenosynovitis, with the flexor carpi ulnaris the most counters the ground, a resistance that heavily loads
common site of injury.[35] the flexor tendon. In addition, beginner golfers may
experience pain due to extensor carpi ulnaris
Hook of hamate fractures result from the hamate overuse, which is the result of ‘casting’ the golf club
becoming impinged between the hand and the butt early in the downswing (the early uncocking of the
end of the club. This results in a fracture of the wrist during the downswing and a source of lost
hamate of the leading hand, for example the left power and control).[43]
hamate in a right-handed golfer,[36] and has been
reported in the golf injury literature as far back as Unusual cases of injury in the surrounding struc-
1972.[37] Stress fractures may also occur at this site tures also occur. Hsu et al.[44] reported the case of an
due to sudden increases or changing the golf club amateur golfer with mechanical compression of the
grip.[38] median nerve in the right palm by the head of the
first metacarpal bone of the left hand. This compres-
The site of pain with a hamate fracture is in the sion may occur during the acceleration phase of the
hypothenar area of the palm, with tenderness to downswing just prior to impact, particularly if the
palpation of the hamate an indication for imaging. right hand is leading the left hand during the down-
However, plain x-ray films may not initially show swing and if the right-hand grip is too tight.
the fracture.[36,39] A carpal view x-ray may show the
fracture, although a CT of the wrist should show the Abnormal anatomy along with overuse can also
injury if there this film is negative and there is still a produce injury of the wrist. Oka and Handa[45] re-
clinical suspicion for it. ported the case of a 20-year-old golf trainee present-
ing with right wrist pain when swinging the golf
Complications to the healing of the fracture in-
club during a practise session. Examination revealed
clude non-union of the fracture site, a concomitant
extensor carpi ulnaris tendon dislocation past the
ulnar nerve lesion and/or the rupture of the flexor
ulnar head and to the ulnar-volar side on supination
tendons over the broken edge of the hamate.[35,40]
of the forearm. On returning to the neutral position,
Hook of hamate fractures tend to present late (usual-
the tendon reduced in a snapping manner, extending
ly several months after the injury) and often require
beyond the ulnar head, which reproduced the pain.
surgical excision of the fracture segment at this
Surgery to partially resect the ulnar dorsal ridge of
point.
the ulnar head with release of the extensor rec-
Tendinitis is a much maligned term used to de- tinaculum resulted in resolution of symptoms.
scribe overuse syndrome about the wrist/elbow,
with the term tendinopathy been indicated for use as A highly unusual case of hypothenar hammer
a general clinical descriptor.[41] It has an overuse syndrome in a golfer has been reported. Hypothenar
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
180 McHardy et al.
hammer syndrome results from a thrombus forma- hitting the ball ‘fat’ is poor swing mechanics and
tion of the ulnar artery with hand ischaemia. They with a steep downswing predisposing to hitting the
usually occur in occupations that involve vibrating ball ‘fat’.
tools and those people who hammer objects with Besides the traumatic injuries, overuse injuries
their hypothenar eminence, hence its name. Most often result from changes in the grip of amateurs.
cases that occur in the sporting arena occur in base- Gripping the club too tight and having golf club
ball and are the result of repetitive blunt trauma. In grips that are slippery are also common causes. All
the presenting case, the proposed mechanism was of these factors result in changes in forces generated
the repetitive hitting of practise balls with a ‘faulty’ in the forearm musculature and are a source of
grip causing repeated pressure on the ulnar artery potential injury.[43]
underlying the hypothenar eminence, which resulted In the golf downswing, just prior to impact, there
in injury and thrombus formation.[46] is a large increase in wrist flexor activity, the flexor
McHardy and Pollard[47] have reported of the burst.[49] At this point in time the right wrist is still
unusual onset of wrist pain after a change in the radially deviated and extended, but moving towards
putting grip, which resulted in the supination of the neutral. This combination places a large amount of
right wrist in a right-handed golfer. This grip change stress on the wrist and may result in an acute injury
caused increased stress on the insertion of flexor if the ground is hit or a gradual injury from exces-
carpi radialis and resultant pain. Manual therapy and sive practise due to microscopic damage.[27] Some of
a return to the previous grip resolved symptoms. these forces can be transmitted to the elbow and
result in injury to the medial elbow in the right arm
(trail elbow) in the right-handed golfer or to the
2.3 Elbow Injuries
lateral elbow in the left arm (leading) in right-
The elbow is a common site for injury, particular- handed golfers.[50]
ly in amateur and female golfers. A possible reason To combat these overuse injuries, research has
suggested for this is the increased carrying angle been conducted on the use of braces and larger sized
found in females.[3] Although injury to the common golf grips on the forces generated in the forearm
flexor bundle at the medial epicondyle is commonly muscles. Interestingly, there was no statistical dif-
called ‘golfers’ elbow, it is the lateral epicondyle ference in forces produced between those that used
that is the site of more golf-related injuries. In a the devices compared with those that did not use
study of golf injuries, McCarroll et al.[2] found that them.[49] Even though the elbow is a common injury
of all elbow injuries, 85% occurred to the lateral site in golfers, little research has been conducted in
aspect. Differences in the mechanism of injury are this area. Most of the elbow injury mechanisms and
the likely explanation for this difference. A sudden management plans are based on racquet sports-relat-
deceleration of the club head can result in injury to ed injuries.
the medial aspect of the elbow, while overuse is the
more likely mechanism to occur at the lateral aspect 2.4 Shoulder Injuries
of the elbow.[48] Traumatic injury usually occurs as
the result of hitting an object at impact (other than Shoulder pain in golfers is a relatively common
the ball) during the swing. In professionals, this is occurrence, accounting for approximately 8–12% of
mostly the result of hitting an obscured tree root/ all golf injuries,[2-4] although Gosheger[1] placed this
rock in the rough or trying to hit the ball out of heavy figure at 17.6%. That playing golf causes suscepti-
rough (for example St Andrews at the British Open). bility to shoulder injuries is unusual as the sport is
This may also occur in amateurs. In addition, a more not an overhead sport that requires elevation of the
common mechanism involves the amateur hitting humerus. When the humerus is in the overhead
the ground first when attempting to hit the ball position (>90° elevation), the shoulder is susceptible
(hitting a ball ‘fat’). A possible explanation for to instability. Most sports with high injury rates for
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 181
the shoulder complex fall into this category, for what point in the swing produces the patient’s pain.
example swimming, pitching and racquet sports.[51] Tightness of the posterior capsule, posterior capsu-
However, overuse of the shoulder in the form of litis or tightness of the rotator cuff musculature often
excessive practise can produce problems of the causes posterior shoulder pain at the top of the
shoulder, including but not limited to: subacromial backswing. If, however, posterior shoulder pain oc-
impingement, rotator cuff pathology, acromi- curs at the end of the follow-through, impingement
oclavicular dysfunction, glenohumeral instability of either the posterior labrum or the underside of the
and arthritis.[52] rotator cuff muscles may be the source of the pa-
tients’ pain symptoms. Anterior shoulder pain at the
The shoulder goes through a large range of mo- top of the back swing can be caused by impingement
tion including a large degree of left shoulder hori- of the humeral head and anterior labrum, producing
zontal adduction and right shoulder external rotation anterior joint line pain, or the pain may be localised
in the backswing. In the follow-through there is a to the AC joint indicating possible degeneration or
large degree of left shoulder external rotation and impingement of the AC joint.[57]
horizontal abduction and right shoulder horizontal Jensen and Rockwood[58] retrospectively re-
adduction.[53] A study on professional golfers (<3 viewed 24 golfers who had shoulder arthroplasty
handicap, age range 26–63 years) with shoulder pain and found that 23 were able to return to play, the
found that out of 35 subjects (all right handed), all other golfer was unable to return to golf due to
but one had left shoulder pain, 53% (n = 18) report- osteoarthritis of the hip and knee. The 23 that re-
ed pain in the acromioclavicular (A/C) joint and turned to golf had in total 26 shoulder arthroplasties,
41% (n = 14) had some A/C osteoarthritis, while 9% 12 to the left and 14 to the right. All were right-
(n = 3) had distal osteolysis of the clavicle (this handed golfers. Before surgery, 11 patients were
implies a compressional loading to the A/C joint in unable to play golf, but were able to do so after the
the horizontal plane).[54] Hovis et al.[55] found that in surgery. Only three patients reported mild pain dur-
elite golfers, those with shoulder pain in the left ing play and six reported mild pain that resolved
shoulder (lead shoulder in right-handed golfers) had quickly after play. In the same study, surgeons were
posterior instability (eight out of a cohort of eight) asked to complete a survey on patients playing golf
and many had signs of impingement subacromially after surgery. Forty-four responded and 91% en-
(n = 6). They found that the pain and feeling of couraged a return to play. Although this study found
instability was reproduced at the top of the backsw- that arthroplasty results in golfers being able to
ing (maximal horizontal adduction). return to golf, and useful in its findings it raises
In a previous study, Bell et al.[56] found that the more questions than it answers. These questions
position that produced the maximum force across include:
the A/C joint was horizontal abduction and adduc- •Was golf the reason for the shoulder complaint?
tion. These positions are similar to those attained by •What was the previous sporting history of the
the arm at the top of the back swing (left arm
patients and how long have they been playing
horizontal adduction) and at the end of the follow-
golf?
through (left arm horizontal abduction). This posi-
tion is also similar to the anterior instability appre- •Of the 11 patients that were unable to play golf
hension test (the end position). Therefore, A/C joint prior to surgery, how many had left shoulder pain
injury in high level golfers may be associated with and how many had right shoulder pain?
anterior glenohumeral instability and repetitive It is known that previous studies have shown that
loading of the A/C joint from hitting a large number the left shoulder is more likely to be injured by
of golf balls per day. golfers due to larger movements and stress posi-
When a patient presents with shoulder pain due to tions, even though the game of golf is less likely to
the golf swing, the practitioner should ascertain at injure the shoulder compared with overhead sports
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
182 McHardy et al.
such as swimming, baseball and cricket.[51] The sidered a confounding variable in measures of range
study could make no conclusion as to the aetiology of motion, power, etc. Much of the fall could be
of the shoulder complaints. A prospective long-term explained by aging as opposed to any consequences
investigation is required to provide answers to such associated with the procedure.
questions. Although extremely uncommon, fractures of the
patellar due to golf have been reported in the litera-
ture.[62,63] A case study reported a golfer who exper-
2.5 Knee Injuries
ienced a patellar osteochondral fracture during the
Although knee injuries are not a leading cause of follow-through of a drive.[57] Internal rotation of the
golf injuries (approximately 6%),[1-4] the forces pro- femur on the tibia was the proposed mechanism of
duced in the knee can be large. The right knee has its injury. The patellar slides tangentially over the later-
peak force at the end of the backswing when the club al femoral condyle with the knee in the flexed posi-
is moving slowly (compression 540N). The left knee tion, which may result in an oesteochondral fracture
has its peak force near impact and follow-through of the patellar or femoral condyle.
(compression 756N).[59] Add to these compressive A second case study reports a fracture of the
forces, the fact many of the golfers are older and patella following reconstruction of the anterior cru-
experience osteoarthritis in the hips and knees (with ciate ligament (ACL).[58] Six months after an ACL
reduced range of motion), the issue of the effect of reconstruction, the patient was told that he could
golf on arthritic knees needs to be evaluated. Also as increase activity. He started to hit golf balls. The
many in the golfing population may have undergone patient initially tried short irons, which were okay.
total hip or knee replacements, the question of the He then attempted to use the driver. On the first
replacement on golfing activity is of much interest. attempt, he felt a pop with immediate pain and
Mallon and Callaghan[60,61] conducted surveys of swelling. X-ray revealed a transverse fracture of the
both golfers who had a total knee replacement and patella.
also knee surgeons. They found that most (87%) had
no pain during play and only 35% reported mild pain 3. Major Injury – Head and Eye Injuries
after play. However, pain in the left knee during play Although very uncommon, injuries to the head
and pain after play was statistically different (p < and eyes occur in golfers. A relatively large body of
0.01) to pain in the right knee. Most surgeons (94%) literature is devoted to this type of golf-related inju-
did not discourage golf and 90% reported not giving ry.[64-74] Most injuries are the result of being struck
any particular instruction to patients, while the re- by either a stray golf ball, or getting struck by the
mainder told patients to start with short shots and club head of a fellow competitor during their swing.
also use a shorter, easier swing after the procedure.
This mechanism of injury is extremely uncom-
Seventy-two percent of surgeons thought golf would
mon, but has the potential to cause the greatest
not affect those with a knee replacement, while two-
amount of injury. Due to the size of the ball and the
thirds recommended the use of a cart whilst playing.
speed that it can achieve, damage to the region it hits
The average age of the respondents was 65.4 years
can be quite large. The same can be said for being
who played golf 3.7 times per week. Handicap in-
struck by a club. Standing behind someone who
creased by 1.9 strokes compared with their handicap
unexpectedly takes a practise swing or standing too
at the time of the operation, while they lost 11m
close to them during a golf swing is the most com-
(12.2 yards) off their drives. However, the average
mon source of this injury mechanism. This is partic-
follow-up period from the operation was 4.7 years.
ularly true for the younger population.
Whilst these figures appear to suggest falling per-
formance following total knee arthroplasty, the fact A 1991 study at a regional referral centre for
that the operation was, on average, 4.7 years earlier children with head injuries found that, over 1 year,
and the subjects were 4.7 years older must be con- 11 golf-related injuries were seen (232 total head
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 183
injuries and 27 sports related).[64] All of these chil- ments at the University of Michigan hospital report-
ed nine golf-related ocular injuries.[67] Seven of
dren were boys with nine sustaining skull fractures
these injuries were the result of being struck by a
(seven required surgery to elevate a depressed frac-
golf ball, with the other two the result of being
ture). Nine injuries were the result of being struck by
struck by a golf club. Eight of the nine patients had a
a club and two by a golf ball. Interestingly, only one
ruptured globe. Enucleation of the eye was required
was sustained on the golf course and none of the 11
in six patients. Being struck by a ball accounted for
had adult supervision. Overall, these 11 injuries
four of these procedures and two resulted from club
sustained accounted for 40% of all the sports-related
head strikes. Interestingly, if the subject was wear-
injuries seen, 50% of all depressed skull fractures
ing glasses at the time of being struck by the golf
seen, 18% of all skull fractures and 4.7% of all ball, only one out of the four patients required
hospital admissions. Care must be taken to reduce enucleation. A further case study demonstrated a
the chance of these incidents occurring by having an optic nerve avulsion as a result of a 10-year-old
adult supervise children playing golf. This adult child being hit by a golf club.[68]
needs to know how the swing works so as to keep
Head injuries as the result of falling out of a golf
the children a safe distance from the child swinging
cart are rare occurrences but have been reported in
the club and also not in front of where the ball is
the literature. Tung et al.[74] reports on three cases of
being aimed. Sensible supervision can possibly
head injuries from golf buggy falls. One case sus-
eliminate the majority of these injury cases.
tained a moderate head injury with a small cerebral
Around the golf course, players can be hit by a contusion and skull fracture. Two cases sustained
stray ball. The shouting of the word ‘fore’ is the severe head injuries involving extensive cerebral
common way of informing golfers that a golf ball is contusions and extradural haematoma, which re-
headed in their direction. To reduce the chance of quired craniotomy. Two of the three made good
being seriously injured when this occurs, the golfer recoveries, the other remained in a vegetative state.
should keep in the same spot, turn their back to the What cannot be answered from these studies was the
call and duck down whilst covering their face and cause of the fall and if age was a factor in a fall from
head with their hands. Many times on the golf the cart, or was negligence a factor (i.e. cart drivers
course you see golfers responding to the call of not following appropriate instructions for use)? Be-
‘fore’ by turning in the direction of the call and cause of increased litigation, all golf buggies have
looking up into the air. This position exposes the handling instructions informing occupants of the
face, eye and head to the flight of the ball, which can risks associated with their use.
cause significant damage if it strikes these areas.
Eye injuries as a result of golf can sometimes 4. Other Injuries
occur.[67] However, compared with sports such as
racquet sports (squash in particular), football and Although uncommon, other types of injuries can
hockey their occurrence is extremely low.[75] occur on the golf course. These include syncope of a
As stated previously in this section, the golf ball golfer after hitting a drive and turning the head after
and golf club are often travelling high speeds and are being distracted whilst putting.[76] Treatment given
small enough to fit within the orbital rim of the to this golfer was a transvenous ventricular demand
skull. A 1980 case study reported a patient present- pacemaker, with the mechanism of the event being
ing to hospital.[66] History revealed the ball had sinus arrest due to the sudden turning of the head.
travelled approximately 183m and struck the patient Golf is an 18-hole event that takes 4–5 hours to play
in the left eye by a golf ball. Immediate and com- a standard round. This is a long time to be exposed
plete visual loss occurred. X-ray revealed no frac- to the elements, particularly the sun in summertime.
ture. After 2 months there still was no sight in the As a result, sunburn and sunstroke are a distinct
eye. A 6-year retrospective study on patient treat- possibility as is dehydration if inadequate fluids are
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
184 McHardy et al.
consumed. Skin cancer in the form of melanoma is a sity that may positively influence cardiovascular
risk factors, depending on the type of the course.
potential hazard of long-term exposure to the sun, a
As a result, studies into the cardiovascular re-
factor that may predispose the older golfer to this
quirements during golf have found that golf on a
condition. In cold and wet conditions, hypothermia
level course can be considered an activity that pro-
is a rare occurrence, although frostbite of the toes vides a level of cardiovascular exercise that is in a
may occur in non-waterproofed shoes. Anecdotal safe range, and has potential benefits. However, on
evidence suggests that many golfers acquire an al- hilly courses, the cardiovascular effort required by
most fanatical zeal to the game. This results in golf may potentially result in the exceeding of a safe
golfers continuing to play despite adverse environ- level in those with cardiovascular insufficiencies.
mental conditions. In poor weather, lightning strikes
can occur.[77,78] Popular professional Lee Trevino
was struck by lightning in 1975 playing in the West- 4.1 Stress Fractures
ern Open at Butler National Golf Club in Chicago.
The freak accident permanently damaged the flexi- Stress fractures are the result of overuse and may
bility and sensitivity of his lower back, but with a occur in any area of the body that is subjected to a
series of operations, he was able to recover from sudden increase in stress.[90,91] Previous studies on
injuries sustained and go on to the upper echelon of stress fractures reported on 169 patients with a stress
golf.[79] Although uncommon, lightning strikes can fracture and found that the ribs were the third most
cause serious injury to the cardiovascular and neuro- common injury site and that golf was the fifth most
logical systems.[80,81] common sport (out of 19) for them to occur.[92] In
golf, there have been case reports of stress fractures
Golf is not considered to be a strenuous activity. of the ribs,[93-95] the ulnar diaphysis,[96] the tibia,[97]
Research has shown 108 beats/minute to be the the sternum[98] and the hook of hamate.[37-39]
mean heart rate over 18 holes in healthy middle- A study was conducted on beginner golfers (<1
aged men.[82] Further studies have been conducted year of golf). It reported on 11 golfers with a chief
on the effects on hilly courses on heart rate.[83,84]
complaint of anterior, posterior or lateral chest pain.
They report that a peak of 70% in males and 80% in X-ray and bone scan analysis resulted in the diagno-
females of maximum heart rate was found on some sis of rib stress fractures. All lesions were found on
hills. Considering that individuals in the older age the posterolateral segments of the ribs, six on the
groups play golf, there is seen a decrease in cardiac right and eight on the left (three golfers had two
output with increasing age and it is often in these fracture sites). Of note, those players with right-side
older groups that cardiovascular insufficiencies tend fractures had a history of divot taking with their
to be present, the golf course is a potential site of swings. All patients reported hitting around 400
cardiovascular problems for golfers.[85,86]
balls per week. The forces acting on the ribs by the
Parkkari et al.[87] found that walking during golf serratus anterior due to the retraction and protraction
was a safe form of activity in healthy sedentary of the scapular during the golf swing was the pro-
middle-aged males, while study on the cardiovascu- posed mechanism for stress fracture of the ribs.[93]
lar load whilst pulling a cart at golf for nine holes A case of ulnar diaphysis stress fracture was
showed that for players without heart disease the reported in a middle-aged golfer (handicap 30) who
game provided an adequate training stimulus.[88] reported left wrist pain of no sudden onset. She
The same study found that for those with heart reported playing golf everyday, and had been re-
disease and/or are less fit, there was a chance that ceiving professional tuition. There was no report of
they could exceed their safe activity level.[88] Con- hitting the ground or casting of the club in the
versely, Unverdorben et al.[89] found that competi- downswing. The mechanism of injury was thought
tive golf in cardiovascular patients reached an inten- to be supination and overuse of the flexor muscles of
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Golf Injuries 185
the hand. The authors proposed that the injury oc- that further research into the epidemiology of golf
curred during the follow-through.[94] injuries be conducted. The authors are presently
conducting a large scale, prospective study on golf
Stress fractures of the tibia usually occur in the injuries in Australia that is aimed to fill the gap that
transverse plane, involve the diaphysis and occur in is in the golf injury literature.
athletes and the military. Whilst it is uncommon to
be found in golfers, a study reported the occurrence Acknowledgements
of complete distal tibia stress fractures in two pro-
fessional male golfers.[95] Both stress fractures oc- No sources of funding were used to assist in the prepara-
curred in the left shin, resulting in spiral fractures of tion of this review. The authors have no conflicts of interest
the tibia and in one case the fibula as well. Both that are directly relevant to the content of this review.
golfers reported a history of shin pain for a few
months previous to the fracture with one receiving References
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