Reed, Jeremy J.; Wadsworth, L. Tyler
INTRODUCTION AND EPIDEMIOLOGY
Golf is a popular sporting activity all over the world. According to the National Golf Foundation, 28.6 million people aged 6 yr and older played golf in 2008 (23). Unlike most sports, frequency of play may actually increase with age. It provides low levels of activity, but over extended periods of time, and without physical contact. Walking the course while carrying a bag requires the same caloric expenditure as walking 3.5-4 mph continuously, which exceeds the physical activity guidelines of the American College of Sports Medicine (26). It also provides a social setting in which to spend time with friends.
Injuries of the low back were the most frequently reported injuries in golf in a prospective trial, with injuries of the elbow and forearm being close second (20). This holds true for male professional golfers, as well. In another study of female professional golfers, low back injury was reported second to left wrist injury (19). While overuse is a common cause of injury, injuries seemed to occur during the swing at impact and during the follow-through phase.
Although golf commonly is associated with low back pain, it may not have a significant effect on the incidence of back pain. In a 12-month study of beginning golfers, the incidence of new-onset back pain was similar to age-adjusted general populations (3). However, the incidence of pain was higher in subjects who played only golf (13%) versus involvement in concurrent sports (5%), suggesting that inactivity prior to taking up golf may be a separate risk factor. One study found that golfers actually had a lower risk of disc herniation than nongolfers, with a risk ratio of 0.19 for those who played two or more times weekly (21).
It is well known that the golf swing is a complex and asymmetrical movement (5,12). The spine in particular is exposed to significant axial twisting, compression, anterior-posterior shearing, and lateral bending during the swing (8). In general, development of back pain in amateur golfers is related to poor swing mechanics and poor physical conditioning versus overuse injury in professional golfers (13). During the swing, compression forces on the spine reach eight times body weight in both professional and amateur golfers (13). This approaches that of football linemen hitting a sled and is considerably higher than the force needed to prolapse intervertebral discs in cadavers (8).
The modern golf swing has been quite popular since the 1960s. With its stress on limited hip and pelvic rotation at the top of the backswing, and the initiation of the downswing with the hips while the shoulders and torso are still "loading" in the backswing (otherwise known as torso-pelvic separation, or the "X-factor"), is much different than the more upright classic swing of old. In the classic model, the hips and shoulders tend to rotate together, leading to less rotational stress on the lumbar spine, and less lateral bending at impact. These differences, along with the lumbar hyperextension during follow-through (the "reverse C" position) found in the modern swing, have been implicated as potential pain generators in the modern golfer (13,22). Twisting or torsion of the lumbar spine is associated with low back injury because of the relative intolerance of the lumbar spine to rotation (2). It has been shown that golfers suffering from low back pain achieve backswing axial rotation that surpasses their pain-free, comfortable maximal rotation in the neutral position (17). This is significant, given that merely 2°-3° of intersegmental rotation can produce trauma to lumbar facet joints (8). Moreover, compression, torsion, and lateral bending have been shown to be the most common mechanisms for disc herniation (8).
Trunk musculature acts to stabilize the spine during the golf swing. A study looking at erector spinae muscle activity of golfers with low back pain and golfers without pain found more activity in the pain-free group (5). Also, golfers with pain seem to fire these muscles before starting the backswing, while golfers without low back pain do not (6). Internal and external oblique activity does not differ significantly between asymptomatic control group golfers and ones with chronic low back pain, however (12). Transversus abdominus activity was not studied.
TYPES OF INJURY
Back pain in golfers can present in many ways. As with back pain in other sports and activities, typical causes of pain include mechanical pain, such as muscle strain or spasm, discogenic pain, spondylogenic pain, or pain related to facet arthropathy (13). However, all etiologic factors must be considered, including infectious, autoimmune, oncologic, abdominal, or pelvic visceral causes, as well as psychogenic factors.
Mechanical lower back pain is one of the most common reasons a patient sees a physician. It generally is characterized by localized pain, associated muscle tightness, and spasm, and it usually begins gradually (13). It generally improves with relative rest and may be exacerbated by movement, such as swinging a club. As noted previously, both swing mechanics and overuse can play a role (13,28). In older golfers, osteoarthritis of the hip may play a role in mechanical back pain. It is thought that decreased internal rotation of the lead hip during the swing may translate more force to the lumbar spine, causing mechanical elements to be stressed (4). In younger populations, other factors such as a sudden growth spurt, leading to relative tightness of the lumbodorsal fascia and hamstrings and stress on the spine, should be considered (11).
Other mechanical factors can cause pain in the low back. Sacroiliac joint dysfunction is an increasingly recognized cause of back pain, especially in young and active populations, accounting for up to 40% of injuries to the low back (1). Symptoms can mimic low back strain or can be located in the buttock or posterior thigh. There is usually localized tenderness over the joint, and asymmetry of pelvic landmarks (11). Leg length discrepancy can play a role as well, causing unequal transmission of forces through the spine during any weightbearing activity (11). Also, improper club fit can affect swing mechanics.
Disc herniation is another common cause of back pain in golfers and nongolfers alike. The classic patient is one whom experiences acute onset of pain, sometimes with an associated "snap" felt in the low back, and most commonly in the third decade of life (13). The pain over the next 24-48 h will begin to radiate down the leg in a specific dermatome. As the L5-S1 disc is the most common herniation site, the S1 nerve root commonly is affected. The pain commonly is worsened by sitting, coughing, and the Valsalva maneuver. The leg pain typically is worse than the back pain. Physical exam reveals radicular pain exacerbated by the straight leg raise test. A complete neurologic exam should be conducted, documenting any sensation or motor deficits, as well as reflex changes. When present, these should be followed quite closely until resolved. Diagnostic modalities such as magnetic resonance imaging (MRI), nerve conduction studies, and electromyography may be needed. Although rare (0.79% of lumbar discectomy cases in one study), lumbar disc herniation must be considered in the adolescent population as well, as intense sports participation is a recognized risk factor (24).
Spondylolysis is a relatively common cause of low back pain in the young athlete. It is characterized by a defect in the pars interarticularis, near the junction of the pedicle and lamina, thought to be caused by repeated hyperextension (11). Pain is typically exacerbated by hyperextension or rotation with the back in a hyperlordotic position. This, along with tenderness just lateral to the midline, can be reproduced on exam (13). With bilateral spondylolysis, there is risk of spondylolisthesis or sliding forward of the affected segment. This can cause radicular symptoms that would be more typical of discogenic pain.
Facet joint pain can mimic spondylolysis in that pain can be exacerbated by hyperextension (11). Compression and rotational forces also have been implicated (13). In young athletes, the process is a painful irritation of the joints (i.e., a synovial reaction), whereas osteoarthritis can affect facets in older patients. The highly compressive and rotational forces during the swing and forceful hyperextension of the modern follow-through all can play a role in the development of facet pain. Patients typically do not have radicular pain, but if facet osteophyte formation or hypertrophy is robust, the nerve exiting at that level could be involved (13).
In senior golfers, vertebral compression fractures must be considered, particularly in postmenopausal osteoporotic women (7). A recognized but rare cause of back pain in golfers is stress fracture of the ribs. Ribs 4-6 were the most common encountered in one study (18). Serratus anterior weakness seems to be the culprit. One commonly seen cause of chronic back pain is the myofascial pain syndrome, which is characterized by palpable, localized, tender "trigger points." These commonly are located along the paraspinal and gluteal muscles (24).
TREATMENT AND PREVENTION
Although specific treatment plans should address the specific injury, treatment of low back pain in the golfer should include sport-specific rehabilitation and instruction on proper swing mechanics (28). In terms of mechanical back pain, acute injury will typically resolve within 2-4 wk. A period of relative rest and analgesics with gradual return to play as tolerated usually is adequate. More than 2-4 wk of pain could suggest a more serious injury and requires reevaluation.
Management of disc herniation has not been well studied in athletes. One study, though, found that 79% of athletes were able to return to their sport after conservative management of symptomatic herniation in an average of less than 5 months (14). Typical conservative management includes relative rest, such as avoidance of activities known to cause increased pain, and antiinflammatory medication, including oral corticosteroids (29). This should be followed by intense trunk stabilization exercise and gradual asymptomatic return to play. An older study found that 44% of studied athletes had rapid relief following epidural steroid injection for disc herniations with an average prior symptom duration of 3.6 months (15). The authors noted that the improvement rate was less than published larger studies of the general population at the time. In general, epidural injection has not been well studied in the athletic population. If patients fail conservative management and there are clearly defined neurological deficits, surgical treatment can be considered (13). Facet joint pain typically is treated with relative rest and analgesia, followed by rehabilitation. Facet joint corticosteroid injection is another option. Myofascial pain usually responds to treatment for mechanical back pain, but trigger point injection and "spray and stretch" techniques can be beneficial as well (27).
Trunk stabilization exercises have had a profound effect for patients with low back pain. In general, golfers with back pain should be coached to swing around a stable spine (28). Dynamic stabilization exercises of the transversus abdominus and multifidus muscles have been shown to decrease intensity of paraspinal firing throughout the swing, decrease pain, and allow return to play (10). In another study, transition to the more classic swing was used (8). Some have suggested that shortening the backswing could decrease back injury without decreasing club head velocity or swing accuracy (2). Using proper warm-up and stretching led to an approximate 60% injury reduction in golfers who did so for at least 10 min before play (9). Improving aerobic endurance may help decrease fatigue, which is a risk factor for injury. Specific training programs for golf can be found in the literature and should provide guidance for any golfer or physician (1,16). Involving the physician, therapist, and a golf professional instructor can improve patient odds of successful return to play (98% with no new golf-related injuries after 1 yr) (25).
Although golf is a low-intensity sport, injuries do occur, frequently to the spine, and often related to overuse or poor swing mechanics. Caring for back pain in the golfer requires an accurate diagnosis to guide appropriate management. Although most acute episodes of low back pain in golfers will resolve spontaneously, chronic back pain may require adjustments in swing technique and physical rehabilitation. Adjustments in swing technique should be done with instruction by a teaching professional. Occasionally, more invasive treatments are necessary, including spinal injections and surgery.
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