The document discusses common golf-related injuries and their management, including injuries to the low back, shoulders, elbows, and wrists that can result from the repetitive motion of the golf swing as well as from acute trauma. Examples of specific injuries covered include low back pain, rotator cuff tendinitis, labral tears, medial epicondylitis, and DeQuervain's tenosynovitis. Prevention strategies and treatment options ranging from rest, physical therapy, and injections to surgery are also reviewed.

1. Back to the Swing of Things
the Basics of Golf Medicine
Stephan Esser MD, USPTA

2. • Disclosures
– None

3. Goals
• Why Golf matters?
• Review the “anatomy” of the Golfer
• Common Injuries and management in Golf
• Preventive Strategies
• Run the Cases

4. Case 1
A wiry 65 y/o male avid golfer presents to your
clinic with complaint of Knee pain that started
after 18 holes of golf last Tuesday
He tells you the following……..

5. Case 1
• “I was addressing the ball on the 6th
hole which is
a par 3 and when I teed off and struck my drive I
tweaked my right knee. I was then walking down
the fairway and when I hit the ball with an iron I
took out a big divot and then my knee was
hurting worse. My ball flew over the hazard and
was on the apron and it was slick. As I walked up
on the green I turned and my foot slipped and I
felt a pop on the inside of my right knee. Now it
is swelling and hurting ever since. “

6. Say What?

7. Golf Lingo 101
• Address: Taking your stance and placing your club
head behind the ball.
• Drive: The shot that is made at the beginning of each
hole from the teeing ground.
• Fairway: The area of the golf course that leads from
the teeing ground to the putting green.
• Hazard: An area on the golf course such as a sand
bunker or permanent water.
• Apron: The area surrounding the putting green that
separates the green from the fairway.
• Green: The area where the cup is located.

8. Golf Basics
• Definition:
– a game played on a large open-air course, in
which a small hard ball is struck with a club into a
series of small holes in the ground, the object
being to use the fewest possible strokes to
complete the course.
www.cloudinary.com

9. Golf Basics
• Holes: 9 or 18
• Terrain/Environment: Variable
• Hazards: Water, Sand, Natural Elements
www.warmspringsgolfcourse.com

10. Golf Basics
• Clubs: Used to strike the ball
– Wood/Driver: Wide flat face, propel the ball the
farthest, made of wood, steel, titanium, composite
– Irons: Numbered 1-9, higher number equals more
angled face producing higher loft and shorter distance
of travel
– Wedges: Highly angled club face produces greatest
loft and shortest distance
– Putters: Used to roll the ball on the green and into the
hole
http://www.chiff.com/pics2/golf-club-types.jpg www.globalgolf.com

11. Golf Basics
• Ball: A special ball designed to be used in the
game of golf. Must have a mass no more than
45.93g, and a diameter not less then 42.67mm
and performs within specified velocity,
distance and symmetry limits.
www.bigcommerce.com

12. Golf Basics
• Shoes:

13. Golf Basics
• Transportation
– Walk: up to 13,000 steps in 18 holes ( 3.4miles)
• Carry Bag
• Push Cart
– Ride in Cart
www.southernhillsgolfcourse.com www.ehowcdn.com

14. Why this matters?
• Understand Sport
before you can understand risk
before you can manage injury
before you can prevent injury

15. Why Golf Medicine matters?
• Golf is a $70 Billion Industry
• 24 million Americans
• 465 million rounds
• 15200 golf facilities per year
http://collegeofgolf.keiseruniversity.edu/wp-content/uploads/2016/06/Golf-Statistics.jpg
http://www.mobilegolfevents.net/uploads/2/2/7/9/22799670/2017ngf_golferparticipation.pdf

16. Golf Anatomy
http://www.osteopathyforall.com/wp-content/uploads/2012/04/Golf-anatomy2.jpg
www. Golfsmash.com

17. Golf Anatomy
• Asymmetric
• Unilateral
• Rotational
• Repetitive

18. Golf Anatomy
• Back Swing
• Contact
• Follow Through

19. Backswing
Golfdigest.com

20. Contact/Follow Through
http://www.innerformgolf.com/wp-content/uploads/2017/01/The-Essentials-of-a-Proper-Golf-
Swing-1024x576.jpg

21. Contact/Follow Through
https://www.australiangolfdigest.com.au/wp-content/uploads/2017/10/Jason_Day_SS_01-759x500.jpg

22. Golf Swing
https://media.golfdigest.com/photos/561529cf3765852b06a26968/master/w_768,c_limit/Hideki-
Matsuyama-swing.png

23. Golf Swing

24. • Golf Injuries
http://kcsportspaper.com/wp-content/uploads/2015/04/Golf-injury.jpg

25. Golf Injuries
A survey of golf injuries in amateur golfers
Batt, ME BJSM 1992
• 57% of recreational players reported an injury
in one year
Injuries and overuse syndromes in golf
Gosheger et al, AJSM 2003
• Rates of injury in 703 golfers
• Overuse: 82.6% Acute: 17.4%

26. Golf Injuries
• Recreational (Combined studies)
– Low Back 15-34%
– Elbow 25-33%
– Wrist 13-20%
– Shoulder 8-21%
– Males: Inc. rate of Back Pain
– Female: Inc. rate of Wrist, Elbow and Shoulder
Pain

27. Golf Injuries
• Professional (Combined studies)
– Male
• Low Back 25-36%
• Left Wrist 18-28%
– Female
• Left Wrist 12-36%
• Low Back 22-27%
– Mechanism:
• High frequency of golf swing
• Striking an object other then the ball

28. Rates of Injury
One Year Follow-Up Study in Australian Amateur
Golfers Mchardy et al AJSM 2007
– 15.8 Injuries per 100 Golfers, 0.3-0.6/1000hrs/ath
– 18.3% Lower Back/Elbow Forearm 17.2%/Foot ankle
12.9%/Shoulder, Upper arm 11.8%
– 46.2% Sustained during golf swing
– 23.7% occurred at Contact/ 21.5% follow through
– Total amount of game play and changes in golf clubs
– No relationship with age, gender, handicap, practice
habits, warm ups

29. Golf Related Injuries
Golf Related injuries treated in US ED’s
Walsh et al AJEM 2017
• 1990-2011 663,471 individuals > 7 y/o
• 12.3/10,000 golf participants
• 23.4% Injured by golf club
• 16% struck by a golf ball
• Location: 36.2% head and neck
– Sprain/Strain 30.6%
• Highest those 7-17 years and those > 55

30. Risk for Injury
• High frequency of play
– Repetitive Microtrauma
• Inadequate overall Conditioning
• Poor Flexibility
• Failure to warm-up properly
• Poor Swing Mechanics
• Striking the ground with the club

31. Types of Injury

32. Back Pain
• Impact and follow through account for most
low back injuries Golf-related lower back injuries: an epidemiological survey,
Mchardy A, J Chiro Med 2007
• Types of Injury
– Facet Irritation -Muscle Strain
– Disc injury -Irrit. Of Spondylolysis
– Si Joint Dysfcuntion -Cluneal nerve irritability
• Average Low back golf injury lasts 2-4 weeks
Lower Back Pain in Golf: A Review Reed JJ, CSMP, 2010

33. Axial Loading
Forward Flexion
Rotation
Side Bending
Extension
Rotation
Axial Loading
Forward Flexion
Rotation
Side Bending
Extension
Rotation

34. Low Back Pain
• Not all athletes demonstrate same patterns
• McHardy A, Pollard H, Luo K. Golf injuries: a review of the
literature. Sports Med 2006;36:171–187.
– Amateurs showed 80% more lateral bending and
peak shear loads and 50% more torque

35. Management
• Excellent clinical exam and imaging as needed
• Avoidance of pain provoking behaviors
• Pain reduction
– Ice/Heat/Massage/Topicals/Medx/TENS
Acupuncture/PT/DC/ Injections etc
– Surgery where indicated
• Therapeutic Recovery
• Swing/Technique Evaluation
• Return to sport
Join me for the back exam
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Join me for the back exam
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36. Management
• Multidisciplinary Team Healthy Swing: A golf rehab model AJPMR 2002
– 98% return to sport
• Physician trained in MSK medicine
• Physical Therapist
• PGA certified Golf Professional

37. • Lindsay DM, Vandervoort AA. Golf-related low back
pain: a review of causative factors and prevention
strategies. Asian J Sports Med 2014;5:e24289.
• 1: Avoid Too’s
• 2: Seek Professional guidance
• 3: Improve trunk rotation and flexibility
• 4: Maintain hip rotation especially on the lead side.
• 5: Make Technical modifications as guided

38. Cases
• A 79 y/o male avid golfer presents to clinic with
central low back and right lateral thigh pain and
tingling. He reports prolonged standing and
walking worsen his symptoms and sitting or
walking while holding a shopping cart improves
his pain.
• On PE you note he walks with a FF lumbar
posture and has a grossly intact neuro exam of
the BLE’s and FPFROM of the bilateral hips
• Diagnosis?

39. • Spinal Stenosis with undifferentiated Right
Lumbar Radiculitis
• Tx: PT, Medx of choice, HEP, etc
– If persistent symptoms despite, consider MRI to
guide spinal injections

40. • Upper Extremity Injury in the Golfer

41. Upper Extremity Pain
• Causes: Misuse/Overuse/the Too’s/Club
Changes/Technical Error/ Acute traumatic
• Diagnosis to consider
– RTC Syndrome
– Labral Tear
– Medial/Lateral Epicondylitis/-osis
– Dequervain Tenosynovitis
– ECU Tendonitis/Tendon tear
– TFCC Injury
– Hook of the Hamate fracture
http://journals.sagepub.com/doi/abs/10.1177/0363546504267346

42. RTC Syndrome
• Presentation: Pain in or around the
shoulder worse with reaching
overhead, behind the back or away
from the body
• Functional: Pain with sleeping on the
side, dressing/undressing/ extremes of
backswing or follow through
• Exam: + Empty Can, Hawkins, Neers,
Painful Arc Test, possible pain with
resisted ER

43. RTC Syndrome
http://www.golftoday.co.uk/proshop/features/2009/images/ernie_els_swing_sequence_12.jpg

44. RTC Syndrome
• Management: NSAIDs, Ice, HEP, PT, Acupunc,
Steroid injections, PRP, Surgery
• Imaging: Failure to improve with 2-4 weeks of
conservative care, severe pain
• Xray Findings US Findings
Boneschool.com https://ars.els-cdn.com/content/image/1-s2.0-
S0378603X15002545-gr1.jpg

45. Labral Tear
• Presentation: Pain often on front
or deep within the shoulder,
worse with weight bearing, rapid
movements, sense of clicking or
instability, worse at limits of
backswing and follow through
• Function: Increased pain during
and after activities which load the
shoulder joint
• Exam: + Obrien’s, + Crank, + Load
http://www.peterhallam.info/wpimages/wp66448036_05_06.jpg

46. Labral Tear

47. Labral Tear
• Management: NSAIDs, Ice, HEP, PT,
Glenohumeral injections, PRP, Surgery
• Imaging: Failure to improve with 4 weeks of
conservative care or severe pain, impaired
function and QOL
• MRI with fine cuts on > 1.5 Tesla or MRA

48. Surgery Vs Non-Surgery
• Sham surgery versus labral repair or biceps tenodesis for
type II SLAP lesions of the shoulder: a three-armed
randomised clinical trial Schroder et al BJSM 2017
• A double-blind, sham-controlled trial was conducted with 118 surgical
candidates (mean age 40 years), with patient history, clinical symptoms
and MRI arthrography indicating an isolated type II SLAP lesion.
• Randomized to labral repair (n=40), biceps tenodesis (n=39) or sham
surgery (n=39)
• Primary outcomes at 6 and 24 months were tracked
• Conclusion Neither labral repair nor biceps tenodesis had any significant
clinical benefit over sham surgery for patients with SLAP II lesions in the
population studied.

49. AC Arthropathy
• Presentation: Pain over the top of the AC
Joint, worse with reaching across to the
opposite side of the body, direct pressure,
body loaded exercises
• Function: Increased pain reaching across the
body or overhead, worse in follow through
• Exam: + Cross Body Adduction, TTP

50. AC Arthropathy
• Management: Rest, avoidance of pain
provoking activities, Ice, Topicals, NSAIDs,
injections, Clavicular Resection
• Imaging: Xrays, US, MRI
https://www.eorthopod.com/images/ContentImages/shoulder/shoulder_acromioclavicular_arthrosis/shoulder_acromioclavicular_arthrosis_intro01.jpg

51. Medial Epicondylitis/osis
• Presentation: Pain over medial elbow worse
with wrist volarflexion, or ulnar deviation
• Functional: Pain with lifting with palm up,
rotating wrist
• Exam: Pain with resisted wrist flexion,
forearm pronation, pain with manual
palpation of the medial epicondyle
http://www.flspinalcord.us/flexors-of-the-forearm/

52. Medial Epcondylitis-osis
• Management: Rest, Lift with palm down, Ice,
forearm brace, topical creams, ASTYM,
Graston, PT, Acupuncture, Needle Tenotomy,
PRP
• Avoid: Steroid injection
• Imaging: Xrays if impaired ROM, pain after
trauma, skeletally immature athlete, “red
flags”, failure to improve
• MSK US: if possible MRI: If no progression

53. Dequervain’s Tenosynovitis
• Cause: Tendonitis of the abductor policis
longus and extensor policis brevis
• Presentation: Pain on the radial side of the
wrist with mild inflammation worse with ulnar
deviation of the wrist
• Function: Impaired golf swing at extremes of
backswing or follow through
• Exam: + Finkelstein test, TTP
http://www.aidmycarpaltunnel.com/_img/finkelstein-test.jpg

54. Dequervain’s Tenosynovitis
• Management: Rest, Ice, Splint, Steroid
Injection, Rarely requires surgery
• Imaging: If trauma, FOOSH, recurrence,
significant swelling, enlargement of wrist
– MRI > MSK US > Xray

55. ECU or FCU Tendonitis
• Presentation: Pain over the ulnar side of the
distal volar or dorsal wrist, worse with ulnar
deviation and flexion or extension
• Function: Impaired activities requiring ulnar
deviation
• Exam: TTP over distal dorsal/radial ulnar
wrist, swelling, pain worse after prolonged
play and sore for more prolonged period

56. ECU or FCU Tendonitis
• Management: Avoid provoking activities,
wrist splint 2 weeks, Ice, PT as needed, steroid
injection or PRP injections for recalcitrant
cases, Surgery
• Imaging: MRI Wrist to evaluate extent of
injury if failure to improve with conservative
care, trauma, recurrent history
https://www.researchgate.net/profile/Philip_Blazar/publication/26781722/figure/fig9/AS:202568673304576@1425307543024/The-
ECU-tendon-white-arrows-with-a-supination-and-b-pronation-In-a-healthy-subject.png

57. TFCC Injury
• Triangular Fibrocartilage Complex
• Cause: Inflammation or tearing of the TFCC due to
repetitive ulnar deviation and rotation or loading
• Presentation: Pain with activities during ulnar
deviation or extremes of wrist extension and
loading
• Function: Hurts with short shots and at contact
• Exam: + Oversupination test, Ulnar Grind, with
ulnar deviation, + Fovea Sign

58. TFCC Injury
• Management: Avoid provoking activities for 2
weeks, Ice daily, NSAIDs, Wrist brace, evaluate
mechanics, technical, PT, Steroid or PRP
injection, Surgery if fail 4-6 weeks.
• Imaging: Xray to r/o fx or OA, MRA test of
choice if fail 4 weeks of conservative care and
considering surgery

59. Hook of the Hamate Fracture
• Cause: Repetitive micro or Single macro
trauma to the palmar side of the hand
– Eg: Hit a “root” when swinging
• Presentation: Pain and swelling over the
palmar side of the base of the hand
• Exam: TTP over region of hamate
http://rockandice.com/wp-content/uploads/2017/09/DrJ225RL.jpg
https://upload.wikimedia.org/wikipedia/commons/thumb/a/a8/Hamate_bone_%28left_hand%29_01_palmar_view.png/1200px-
Hamate_bone_%28left_hand%29_01_palmar_view.png

60. Hook of Hamate Fracture
• Management: Protect, Imaging (Carpal Tunnel
View, Oblique 30 view), Early surgical referral
for excision vs pinning
• Imaging: Xray and CT > MRI
• Excision > Pinning
• Aldridge, JM, Mallon, WJ, Orthopedics 2003 Jul;26(7):717-719
https://www.researchgate.net/profile/Philip_Blazar/publication/40689473/figure/fig5/AS:201529136029701@1425059698612/a-Axial-and-b-
reformatted-sagittal-CT-of-the-wrist-in-a-patient-with-hamate-fracture.png https://josr-online.biomedcentral.com/articles/10.1186/1749-799X-5-
64

61. Lower Extremity Injury

62. Knee Loads
• Risk Factors for Knee Injury in Golf: A
Systematic Review Baker et al Sports Medicine 2017
– 3-18% Knee Injury Prevalence
– No clear dependence on skill level or sex
– > 50 y/o players appear at greater risk of injury.
– Lead knee is exposed to a complex series of motions involving rapid
extension and large magnitudes of tibial internal rotation, conditions
that may pose risks to the structures of a natural knee or TKA.
– Compressive loads ranging from 100 to 440% bodyweight have been
calculated and measured using methods including inverse dynamics
analysis and instrumented knee implants.

63. Contact/Follow Through
https://www.australiangolfdigest.com.au/wp-content/uploads/2017/10/Jason_Day_SS_01-759x500.jpg

64. Management
• Excellent clinical exam and imaging as needed
• Avoidance of pain provoking behaviors
• Pain reduction
– Ice/Heat/Massage/Topicals/Medx/TENS
Acupuncture/PT/DC/ Injections/Bracing etc
– Surgery where indicated
• Therapeutic Recovery
• Swing/Technique Evaluation
• Return to sport

65. Golf Injuries
• Key Elements:
– Increase Knowledge of the Game
– Inquire about changes in technique, volume, club
type, warm up, cool down, cross training
– Perform an excellent MSK Exam
– Develop a Multidisciplinary Team

66. Golf Injuries
• Tips:
– Get to know your local “Golf Professionals”
• https://www.pga.org/directory?showconnections=false
– Find “Golf Certified” therapists
• TPI: http://www.mytpi.com/certification/about
– Try Golf Yourself

67. Other Risk
• Environment
– Heat, Sun Exposure
• Hydration Status
• Insect Exposure
• Other

68. Back Pain
• 30 y/o male business man presents with low
back and left leg pain after working out in the
gym doing deadlifts and then playing 18 holes.
– Exam:
– + SLR on the left, 4/5 ADF and EHL and absent
achilles
– Diagnosis?
L5-S1 RadiculopathyL5-S1 Radiculopathy

69. Wrist Pain
• 45 y/o RH male photographer presents with
pain in the outer left wrist since 1 week ago
when he had a long photo shoot and went to
the driving range at the end of the day and
practiced his “short game” for 2 hours.
– Exam: Pain with ulnar flexion, Pain over the ulnar
side of the wrist, + fovea sign, + oversupination
test
– Diagnosis? TFCC InjuryTFCC Injury

70. Hand Pain
• A 20 y/o RH male varsity golfer presents with
pain and bruising in the palm of his right hand
which started 2 days ago when he struck a
hard root while swinging his golf club.
– Exam: Faint ecchymosis over the palm, TTP over
the medial/ulnar side of the palm
– Diagnosis: Hook of the Hamate FractureHook of the Hamate Fracture

71. Conclusion
• Golf increases the risk of Back > UE > LE
• The “Too’s” should be investigated and
avoided
• Warm Up may reduce risk of injury (< 70%
did) Fradkin et al 2007 and 2003: JSMS
• Total body conditioning, Golf-specific training
• Review anatomy and management regularly

72. Exercise as Medicine
• Golf is an “opportunity”
– Patient who doesn’t want to exercise
– Patient who hates stretching
– Patient who struggles with depression, isolation

73. Thank you!

74. • Additional Resources

75. Golf Injuries
• Incorporate a “Movement Screen”

76. Evaluating Injury Risk
• Goals: Identify changes in your athletes which
place them at risk of injury
• Method: Assess simple movements and
determine if they are
– A: Functional and Non-Painful
– B: Functional and Painful
– C: Dysfunctional and Non-Painful
– D: Dysfunctional and Painful

77. Managing Injury Risk
Plan:
• A: Any “Painful” findings should be referred
for evaluation and treatment by appropriate
medical provider: MD/DO/PT/DC etc
• B: Dysfunctional and Non-Painful can be
treated at home or with a trainer, exercise
coach etc
• C: Functional and Non-Painful: Continue their
successful program

78. Low Back Flexion
• Start with Knees straight,
feet together
• -Athlete should be able to
touch toes
• -Athlete should have a
uniform spinal curve
• -Movement completed
without stress or force

79. Low Back Extension
• -Start with knees straight and feet together and hands over
head
• -Athlete should have uniform spinal curve
• -Arms should be able to reach fully
extended overhead
• -Athlete’s scapula should pass the heels

80. Trunk Rotation
• -Start with feet together and hands by the sides palms facing forwad
• -Athlete rotates entire body as far as possible to one side
• -The hip and shoulders should rotate > 50 degrees
• -There should be no tipping to the side
• -You should be able to see the back shoulder when standing in front of
the athlete

81. Shoulder Reach
• #1:-Athlete reaches up back as high as
possible (repeat opposite side)
-Athlete should be able to touch bottom of
scapula
-Athlete should have equal reach on both
sides
-Athlete should have no pain and should
not
• #2: -Athlete reaches over head toward
opposite shoulder (repeat opposite side)
-Athlete should be able to touch top of
scapula
-Athlete should have equal reach on both
sides
-Athlete should have no pain and should not
“force” the motion

82. Neck Motion
• -Flexion: Athlete brings chin to chest
• -Normal: Can touch chin to chest without major effort or pain
• -Extension: Athlete looks up as high as possible
• -Normal: Can get head up to within 10 degrees of parallel
• -Rotation: Athlete looks over shoulder as far as possible
• -Normal: Can get nose even with clavicle
• -Side-Bend:
• -Athlete should have no pain and should not “force” the motion

83. Single Leg Balance
• -Start with feet side by side
on ground. Lift one leg up till
hip is bent at 90 degrees
• -Athlete stands in this
position for 10 seconds
(repeat other side)
• -Then have athlete stand in
same posture for 10 seconds
with eyes closed (repeat
other leg)
• -Normal is able to remain
stable with both legs, eyes
open or closed for 10 seconds
and the hip does not drop as
time progresses

84. Golf Injuries
• Average age = 54 y/o male
• Age: Sarcopenia, Spinal Arthritis, Loss of
Lumbar, Hip, Shoulder ROM, Inc. Visceral
Adiposity, decr. collagen elasticity, decr.
balance, coordination, reaction time etc
• Disuse: All the above

85. Prevention
• Proper Swing Mechanics
• Warm up prior to play
– Stationary bike, Swim, Elliptical, dynamic
stretching
• Golf-Centric Strength and Conditioning
program
• Equipment Modification