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| | | Year : 2006 | Volume : 40 | Issue : 3 | Page : 188-190 | | | Epidemiology of golf related musculo-skeletal injuries | | | Mandeep S Dhillon1, Sanjay Singh1, Himmat Singh Dhillon2, Jaspal S Sandhu2
1 Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department Of Physiotherapy And Sports Medicine Gnd University, Amritsar, India
Click here for correspondence address and email | |      | |  Abstract | | | Background : Golfing has become an increasingly popular sport enjoyed by both men and women. Although the game is not viewed as hazardous, golfers do sustain injuries connected with the game. However, golf injuries have received little attention in the literature and there is no study from Asia.
Methods : A prospective study was undertaken to analyze the incidence, cause and type of injury among amateur golfers. Open ended questionnaires were sent to 1000 golfers; 240 responded (Av age 51 years, 200 males and 40 females). The respondents played an average of 2 rounds per week.
Results : One hundered and ten (46%) responders had sustained one or more orthopaedic injuries. Both among men and women, the lower back was the most common site of injury followed by shoulder and dorsal spine. There was a difference in the injury pattern in skilled and relatively unskilled players. Lack of warm up, excessive practice and improper swing mechanics were the most common causes.
Conclusion : Golf injuries perhaps could be prevented or reduced by proper technique, controlled practice routines, physical conditioning and pre-play stretching exercises. The most important factor in this playing population seems to be prevention. Keywords: Golf injuries; Epidemiology; Musculo-skeletal injuries How to cite this article:
Dhillon MS, Singh S, Dhillon HS, Sandhu JS. Epidemiology of golf related musculo-skeletal injuries. Indian J Orthop 2006;40:188-90 |
| Introduction | |  |
Golf is becoming an increasingly popular and more readily available sport world-wide; it is gaining popularity in India too, and is being played by people of all ages and with different levels of sporting abilities. Many new players today start golf at an older age (30- 55 years); they come to golf when they feel restricted in other sporting activities such as tennis, jogging, basketball, football, cricket. Many of these middle aged golfers present with injuries, which probably had been brewing in other sports for many years [1] .
Golf is a gentle sport, but not necessarily a benign activity; unlike most other sports, golfers continue to play throughout their lifetimes, and at many golf courses one could see players of an advanced age preparing to "tee off" on any given day. Additionally, although it may not take an enormous aerobic or other anaerobic skill to play well, golf proficiency can only be attained through well directed and sustained practice. All these factors, combined with inadequate coaching and training, and improper facilities, which are the problem in underdeveloped countries, may lead to significant musculoskeletal dysfunction [2] .
Golfers are of 2 types; recreational golfers and those that play professionally. The recreational golfer plays sporadically, has often started without any professional training, plays without proper warm up and generally exhibits swing mechanics that have much room for improvement [2] . In golfers who start at a more mature age, strength and flexibility may already be compromised because of pre-existing or concurrent pathologic conditions related to age. These players would develop a different subset of pathological conditions when they take up the sport. Professional golfers, due to the fact that they play all year round, practice for long periods and have infrequent rest periods, develop an entirely different spectrum of sport related injuries.
Keeping these in mind, it was proposed to analyze the incidence and cause of orthopaedic problems in both amateur and professional players in India. The aim was to see whether the type and intensity of injury was different from that reported in the western literature. We also tried to identify overuse injuries or those resulting from poor technique in amateur golfers (those without professional training) and to define guidelines for therapy and prevention.
| Materials and methods | | |
Over a 2 month period, 1000 questionnaires were posted to members of the Chandigarh Golf Club; 410 golfers responded and 240 of these were interviewed physically. All of these were asked in details about their skill levels (Handicap), duration of playing Golf, frequency of playing Golf, and history of past or present injury,. Players with any golf related injury were taken up for a detailed examination. We tried to find out if skilled training had been imparted to these injured players; age, sex, duration of pre-game warm up, stretching and practice were all noted. Likely cause of injury was enquired about from the players themselves. Attempts were also made to analyze if the problem was occurring in a particular phase of the golf swing, or during impact with the ball. Special note was made of similar previous episodes or injuries; players were asked about preventive measure taken, any external supports or devices employed, and any treatment modalities adopted. After detailed orthopaedic examination, necessary investigations like Xrays and MRI etc were performed where needed.
Data was compiled, and correlated with age, sex, Golf handicap, warm up techniques, swing mechanics, previous history, frequency and duration of playing. Data was tabulated separately for amateur and professional players.
| Observations | | |
Two hundred forty out of 1000 mailed players responded, 200 men and 40 women were verbally interviewed, 110 of which had some kind of Golf related injury (46% of interviewed players). The average age of these players was 51 years and the total number of recorded injuries was 193, with 51 % having a single injury, and 49% having multiple injuries (1.75 injuries per player). The distribution of injuries is given in [Table - 1].
Upon correlation of the proficiency of the players with incidence of injury, we found that better players had a higher injury rate. Players with golf handicap 0-9 had a 61.8% injury rate; players with handicap 10-17 had a 51.8% injury rate, while players with 18-36 handicap had a 36% injury rate.
Back pain was the most common complaint (46.5%). Upon analysis of back injury, the highest incidence was seen in players 41-60 years of age (51%), as well as in players with handicap less than 9 (47%). Mechanical back pain was the commonest (53%) followed by Degenerative disc disease (39%), and spondylosis (8%).
Shoulder region was the second most common problem site (25 cases); 75% of these were more than 50 years of age. We found no correlation with proficiency or duration of playing golf with shoulder problems. The commonest problems in this elderly group were Impingement, rotator cuff tendonitis and tear (48%) and gleno-humeral arthritis and (24%). Sixteen cases of elbow injury/ pain were encountered, with 82% being more than 50 years of age. Lateral epicondylitis was seen in 13 and medial epicondylitis in 3 cases. Better players who played more frequently rarely had any elbow problems. 17 cases with wrist injuries were encountered, with a much higher injury rate in single digit handicappers (better players).
Neck pain in relation to Golf was noted in 19 players, with 68% being more than 50 years of age. No correlation could be found with proficiency and duration of playing. Knee pain was noted in 19 cases, with 68% of these being more than 50 years of age. The commonest cause was osteoarthritis, being aggravated by playing Golf (68%), while 2 players sustained a partial capsular tear and a lateral collateral ligament tear respectively. Dorsal spine pain was noted in 22 players, with equal distribution between old and young players, with better players having a higher incidence of inter-scapular pain.
On attempting sex differentiation, we noted that the lower back followed by the shoulder and upper back were the commonest sites of pain/ injury in males, and the left wrist and elbow the commonest site in females.
Abstinence form golf for varying periods was the commonest form of treatment adopted; 27% of the players never sought medical advice. Lack of proper warm up was the most frequent cause of injury (34.5%), with overuse (21%) and improper swing mechanics (18%) being other major contributor.
| Discussion | | |
Golf is an alluring sport for many reasons; one of them is that there are many different ways for an individual to create an effective golf swing. Each swing appears harmless and yet the accumulation of swings results in repetitive microtrauma to the tissues [3] . Golfing injuries are more likely to occur when an athlete increases this frequency or intensity of playing. Also a change in technique or equipment may predispose an athlete to injuries [4] .
Numerically, the vast majority of problems occur from soft tissue injuries, arising principally, from overuse [5] . The injury seen is influenced by the age of the sportsman, his ability and the amount of play. Anatomically, the few studies available in the western literature show that most injuries are localized to the back, wrist, elbow and shoulder [6] . In addition to causing new injuries, the game may cause recrudescence of old injuries and can exacerbate pre-existing degenerative diseases.
Epidemiologic studies [7] document that back and elbow injuries respectively are the most common complaint in the male amateur golfer. In female amateur golfers, however, the elbow followed by the lower back is reportedly the most likely area of involvement. In the male golf professional, lower back and wrist injuries respectively are more frequently seen, whilst wrist injuries, followed by low back injuries are the most common presentation in the female professional golfer. Injuries are related to overuse, poor conditioning and improper swing mechanics [8] and most can be prevented by proper training and advice.
The problem is becoming more pronounced in India, as more people are taking up golf, but the professional training and guidance needed to prevent injury are not routinely available. Injuries to the recreational weekend golfer have not been studied at all. The innocuous appearance of golf as a sport has probably caused most practitioners not to expect many injuries from it; however, as has been shown by our study, injuries do occur in the amateur golfer.
Our preliminary work has tried to reach some conclusions. In this small study, 24% of the players responded; those that did were the regular players. To our surprise we found that barring a few young players, hardly anyone warmed up in a technically correct manner prior to the game. Fifty one years was the average age of the players, which is much higher than in any other sport, and at this age some degeneration of joints and weaknesses of muscles is to be expected. Male players predominated in the injured group, and the injury rate in amateur golfers was 45%. Female players were more irregular and that maybe the reason why their injury profile was less severe as they may have had more periods of rest in between games to recover from the problem.
Injuries directly related to golf (like grounding the club, twisting the knee etc) were less common, while aggravation of pain in pre-existing degenerative conditions like lumbar spondylosis, cervical spondylosis, oa knee and shoulder, rotator cuff tendinopathy was much more frequent. Tennis elbow was much more frequently encountered than Golfers' elbow, and better players injured their wrist more frequently than their elbow. The higher rate of injury in better players was due to the fact that they played more often, and was more competitive in their game; overuse injury was thus more frequent, and since these players did not take time off to recover, chronic injury was more predominant.
Since back pain was the most frequent complaint, we analyzed this in more detail. We noted that amateurs playing golf more than thrice weekly were 4 times more prone to develop back pain, especially in the age group 41-60. Players who had been taught the game professionally, and had better swing mechanics, had a lower incidence of back pain. The swing mechanics of an improperly trained middle aged golfer are never corrected, and this may hasten the onset of degeneration in the lumbar spine, thus explaining the higher incidence of pain.
From the present study we reached the following conclusions. Golf should no longer be considered a benign activity. Although weekend golfers do not place the same demands on their bodies as the professionals do, their bodies are less suited to withstand even these lesser strains. In addition, improper training, and starting the game at an older age may contribute to higher injury rates. Trauma prevention and proper guidance about swing mechanics needs to be stressed from the learning stage. Each Golf course should have a trained professional to impart coaching, and each beginner should be made aware of the potential problems associated with the game and should be encouraged to understand proper warm up techniques. Injury recognition and appropriate medical guidance is essential to prevent a problem becoming chronic and disabling in relation to the game.
| References | | |
| 1. | Adlington GS. Proper Swing Technique and Biomechanics of golf. Clin Sports Med. 1996; 15(1): 9-26.  | | 2. | Jobe FW, Schwab M. Golf for mature athletes. Clin Sports Med. 1991; 10(2): 269-282. | | 3. | Pink MM, Jobe FW, Lewis A, Mottarm YR. Preventive exercises in golf. Clin Sports Med. 1996; 15(1): 147-152. | | 4. | Clancy WG, Hagan SV. Tendinitits in golf. Clin Sports Med. 1996; 15(1): 27-35. | | 5. | Schulenburg CAR. Medical aspects and curiosities of golfing. The Practitioner . 1976; 271: 625-628. | | 6. | Batt ME. Golfing injuries-An overview. Sports Med . 1993; 16(1): 64-71. | | 7. | McCarroll JR. The frequency of golf injuries. Clin Sports Med. 1996;15: 1-7 | | 8. | Burdorf A, Van Der Steenhovern GA, Tromp-Klaren EG. A one year prospective study on back pain among novice golfer. Am J Sports Med. 1996; 24(5): 659-664. |
Correspondence Address:
Mandeep S Dhillon
1090/2 Sector 39-B, Chandigarh
India
DOI: 10.4103/0019-5413.34491
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