Golf Flexibility, The Golf Swing & Common Injuries

Golf would not be considered an impact-sport but golf injuries are common. To avoid injury excellent technique is required for the dynamic golf swing, a repetitive action requiring good flexibility and training. In this article, I take an overview assessment of why golf poses such injury risks, whether any particular player or element of the game carries higher risk and what type of golf injuries can occur.

Ireland has its fair share of golfers. Why wouldn't we with over 400 clubs and 300 courses throughout the country, a few considered to be some of the best in the world. Whether a low handicapper or high handicapper player, there are injury risks that plague every player.

Overuse - most common cause of golf injuries

The most common cause of injury is overuse, reported as high as 82%[1] of all golf injuries. The repetitive nature of the golf swing and not enough rest being taken between play days can place a lot of strain on the golfer’s body. The fundamental skill in golf has to be the golf swing and this is where things can go wrong, not only with ball direction but also potential damage to the golfers body.

Pro's and con's of the modern golf swing

Striking a tiny ball with a small clubface at the end of a long shaft is the respectable skill of the golf swing. Making that tiny ball travel the distance and direction intended requires great skill as well as good body position technique with sufficient specific golf flexibility throughout the full range of motion.

Let’s get into the golf swing of things; the arms move through a large range of motion while linking the golf club and the power-generating torso of the golfer. The golf swing involves 5 phases: the backswing, the downswing, acceleration, early follow-through and late follow-through. With each phase requiring evolving recruitment of muscle activity and fluid technique, there is a risk of soft tissue damage throughout the full swing movement.

The original golf swing is said to have evolved in Scotland some hundred years ago. Modern equipment and material as well as advancement in performance technique have led to the 'modern golf wing' changing the dynamics of required golf flexibility.

Rather than rotating the shoulders and hips as fully as was practised in the original swing, the modern approach[2] restricts the hip turn and uses a larger shoulder turn in order to build torque and power through the lower back and shoulder muscles. The specifics of required golf flexibility has changed somewhat it would seem.

The difference in the rotational angle formed between the hips and shoulders at the top of the backswing is believed to provide greater accuracy and driving distance. However, this greater angular displacement of the spine is thought to be the significant cause of injury for players, both low handicapper and high handicapper. 

Swinging the club vs hitting the ball

Another important consideration is the relative effort of the golf swing. It is believed that if a player tries to 'hit' the ball, where the focus is on the impact of club-face with the ball, the resulting tension in the hands raises the risk for injury.

Compare this to the best players who rather than 'hit' the ball they swing the club 'through' the ball, which is a far smoother swing, appearing almost effortless, with less rigid tension in the upper limbs.

So the objective is letting the club do the work - "Effortless Power; rather than Powerless Effort"
(Thanks Matt!)

Consider the risks to avoid golf injuries

It is estimated[3] that the golfer's body has to absorb a compression force of up to 8 times their body weight on each swing. The swing can be performed between 70-100 times and moreover an 18 hole course, potentially repeating a course multiple times a week. It is easy to understand the high risk of golf injuries if a player does not warm-up sufficiently to have the specific golf flexibility required or does not ensure adequate rest between games.

In one report[4] considering America's 30 million golfing population, it is stated that 60% of low handicapper players and 40% of high handicappers suffer one or more golf injuries every season. This report also attributes this high injury rate to the repetitive nature of the golf swing with the risk increases due to the fact that most golfers appear not to participate in off-season strength training or sufficient pre-game warmup, essential for developing the specific golf flexibility required for the repetitive swing.

Pro's at lower risk

The higher rate of injury in low handicapper players is likely due to the simple fact that they will train and play a lot more than the average high handicapper. However, low handicappers will perform their golf swing with better technique and more efficient load production through the full range of swing motion, lowering their risk of injury caused by a faulty swing, thanks to many hours of training and technique mastery.

For example, in this report on golf injuries and rehabilitation[2], which outlines the lateral bending, shear and compression forces placed on recruited spinal muscles during the golf swing, the study suggests the low handicapper golfer's higher level of efficiency and precision reduces their peak muscle activity by as much as 10% compared to the high handicapper.

The most common golf injuries are to the lower back

The lower back appears to be the most commonly injured body area in golf players, both high handicapper and low handicappers. In a study[5] involving 522 golfers, the most frequent type (67.9%) of injury was a strain, lower back being most common. Of those injured 84% of golfers sought treatment with Physiotherapists being the most common health low handicapper consulted. The majority of golf injuries, in this case, almost 80%, caused performance issues in those who attempted to continue playing.

What's interesting here is the fact that despite injury players did not rest but continued to play even though not being able to play at their best. Playing with an injury weakens the affected body area, reduces your golf flexibility and increases the risk of more severe injury and eventually forced rest and an extended rehabilitation period. I can imagine how a love for the game and perhaps some level of competitiveness provides the sometimes non-sensible motivation to keep on playing.

Why it is important not to delay seeking treatment for a back strain/ injury.

Upper limb golf injuries

Golf Injuries to the elbow seem to be the 2nd most common injury, followed by the wrist. Literature suggests elbow injuries are more common in women golfers and that injuries to the lower back region are more common in men.

The more common elbow injury in women is believed to be due to the increased carrying angle seen in female golfers[6].

A common cause of upper limb golf injuries - hitting the ball fat

Most upper limb injuries in golf occur at impact when the club hits the ball or another object. Thank you to a client of mine for explaining to me that both the pro/ better golfers as well as the high handicap players strike the ground but for possibly different reasons.

The pro/ low handicapper intentionally hit the ground/ take a divot AFTER the ball. This shot is intended to compress the ball making its flight longer and straighter.

High handicappers try to pick the ball often leading to taking divots by hitting the ground, also known as hitting the ball fat, leading to a shot that is shorter. In both situations, the impact of hitting the ground can be felt in the wrists, elbows and even the lower back.

Playing from the rough is also a risk to sustain an injury by striking an unseen rock, tree root or by repeatedly enduring the reduction forces of striking through long grass.

Whether striking the ground before or after the ball or the unseen rock the results are the same; deceleration of the clubhead during the powered downswing phase causing a sudden change in load applied to the club. This change in load can cause subsequent tissue disruption to the hands, wrist or elbow and if the force is significant enough may cause excessive soft tissue elongation in a single swing[6]. If the force isn't enough to cause injury in a single swing it may cause more subtle micro trauma and if repeated several times in a single golf game it is likely to lead to eventual injury, usually to the hand, wrist or possibly the elbow.

Consider your grip

Another potential trigger for a wrist injury in golf could be the simple alteration of how one grips the golf club. Training different swing and strike techniques may lead to small changes in hand and wrist angle and ongoing practise and increased load on the unaccustomed part of the wrist could bring about gradual pain.

Elbow injuries are also sustained at the point of impact, especially those on the ground, tree roots or repetitively hitting through long grass. It is usually the trailing arm that gets injured[6] (right elbow in the right-handed player) and occurs at the point of impact and is known as the medial elbow injury and golfer's elbow.

Gripping the club too tightly may cause changes to the forearm musculature and the forces it sustains potentially leading to a lateral elbow injury, also known as lateral epicondylitis, believed to be the more common elbow injury at a rate of 5:1 in this report of upper limb injuries in golf[6].

Shoulder golf injuries

We have explored above how the golf swing is a dynamic movement and the range of motion of the arms and hips during the 5 swing phases. The shoulder goes through an equally large ROM; during the backswing, the shoulders externally rotate and in the follow-through, there is a large degree of left shoulder external rotation in right-handed golfers.

The shoulder is therefore also at risk of an overuse injury, such injury types accounting for 8-18% of all golf injuries[6].

Shoulder injuries are usually sustained to the lead shoulder and pain localised to the acromioclavicular (AC) joint. Osteoarthritis or horizontal plane compressive loading of the joint are potential long term issues that can develop.

What to consider when seeking treatment for your shoulder pain

Earlier we spoke about the modern golf swing which tends to restrict the turn of the hips during the swing. This restriction at the hips and trunk places more demand on the smaller shoulder rotator muscles to maintain the momentum of the swing which can often lead to shoulder pain or injury.

Save your back, lose your shoulder

A similar cause and effect scenario would be the back pain sufferer trying to protect their backs by limiting their trunk rotation and putting more swing through the shoulders, leading to undesired shoulder problems as a result.

Shoulder impingement or rotator cuff tendinopathy can result from a technique[6] focused on shortening the backswing for purposes of reducing load and force on the lower back yet with problematic consequences on the shoulder.

In summary

• Golf as a sport ticks many boxes
• In Ireland, there are courses to suit every skill and budget
• Walking the 18 hole golf course provides the ideal cardiovascular exercise for promoting optimal health 
• Avoid the common overuse injury - get adequate rest between games
• Always warm up sufficiently before playing to ensure your optimum golf-specific flexibility for the swing
• Off-season training to maintain a conditioned body is a good idea
• Specific strength training exercises must be included in your exercise plan
• The golf swing is a dynamic movement and requires great skill to perfect and avoid injury risk - get low handicapper coaching
• Hitting objects other than the ball causes most upper limb injuries - be extra careful when playing from the rough; be a swinger, not a digger (as the saying goes)
• If suffering a lower back injury a modification to your golf swing should form part of your treatment plan - see your Chartered Physiotherapist and professional golf coach
• Help the spine - use a longer putter and push your cart rather than pulling it

We know many of you would like to increase your clubhead speed. To avoid injury excellent technique is required for the dynamic golf swing, a repetitive action requiring good flexibility and training. For a very informative article about safely increasing clubhead speed, please click here. 

To close with a quote

Golf is the closest game to the game we call life. You get bad breaks from good shots; you get good breaks from bad shots - but you have to play the ball where it lies. ~ Bobby Jones

Enjoy your next game

by Simon. 

References:

[1]Am J Sports Med. 2003 May-Jun;31(3):438-43.

Injuries and overuse syndromes in golf.
http://www.ncbi.nlm.nih.gov/pubmed/12750140/

[2]Phys Med Rehabil Clin N Am 17 (2006) 589–607
Golf Injuries and Rehabilitation
http://www.med.nyu.edu/pmr/residency/resources/PMR%20clinics%20NA/PMR%20clinics%20NA_sports%20med/golf%20injuries%20and%20rehab.pdf

[3]Physiotherapy and golf
http://www.highperformancegolf.com.au/attachments/golfphysio.pdf

[4]Curr Sports Med Rep. 2009 May-Jun;8(3):142-6. doi: 10.1249/JSR.0b013e3181a61c88.
Training to prevent golf injury.

[5]J Sci Med Sport. 2005 Jun;8(2):163-70.
Golf injuries--common and potentially avoidable.
http://www.ncbi.nlm.nih.gov/pubmed/16075776

[6]Golf and upper limb injuries: a summary and review of the literature
Andrew J McHardy and Henry P Pollard
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1175860

[7]Golf injury prevention and performance tips
Hospital for special surgery, http://www.hss.edu