Wadsworth, L. Tyler MD
Golf is a popular participation and spectator sport in the United States. One of the appeals of the sport is that it can be enjoyed throughout the life span by both young and old. It is a sport with modest physical demands, although injuries do occur. Acute injuries tend to occur from carelessness causing the club or ball to strike someone, from the sometimes violent effort used by some golfers attempting to hit prodigious shots, and occasionally by falls on slick or steep surfaces. Chronic injuries are frequently caused by overuse during repetitive practice or play. Environmental and age-related concerns are important to keep in mind when providing medical coverage for golf events. Golf tournaments range in complexity from simple fundraiser half-day events to multimillion dollar, 4-d Professional Golfers' Association (PGA) Tour events.
The goal of golf is to get the ball into the cup in the fewest strokes possible. Each swing, or attempted swing, is considered a stroke. "Par" is the number of strokes the course designer intended to be taken on a given hole. Tournament courses have 18 holes, predominantly comprising holes that play to a par of four, usually with two to six par three and par five holes, for a total course par of 70 to 72. Most tournaments are played according to "stroke play," in which the winner of the competition is the golfer who takes the fewest strokes. Some competitions consist of a single 18-hole round, whereas others occur over several days. Most PGA Tour events are 4-d tournaments played according to stroke play. "Match play" is a competition between two golfers or two teams. The side that holes the ball in the fewest strokes wins that hole. If both sides take the same number of strokes, the hole is tied. The winner of the competition is declared when one side has won more holes than are remaining, or if tied at the end of 18 holes, typically the match continues until one player wins a hole.
A system of handicapping golf competitors is in place to allow golfers of different skill levels to compete equitably. Many amateur tournaments use the Golf Handicap Information Network to equalize the field. Handicap systems are not used in professional competitions.
Several different swing techniques are used to advance the ball to the cup. "The full swing" refers to longer shots, generally greater than 60 yd in distance, in which the goal is to hit the ball to a target down the fairway or to the putting green, which contains the cup. Putting, chipping, and pitching are types of shots used for shorter distances. These swings are different in technique from the full swing and require lower-intensity muscle firing.
Most acute and overuse golf injuries occur as a result of the full swing. Although the golf swing varies considerably, even among professionals, the swing is broken down into basic components common to all techniques: the preswing routine, setup, or address; the backswing; the downswing; impact; and follow-through. The golf swing is asymmetrical and places different demands on the dominant and nondominant sides of the golfer's body. (When referring to "dominance" in the golf swing, references to "dominant" versus "nondominant" refer to the side the golfer is playing from, swinging right-handed versus left-handed, rather than right- versus left-brain dominance).
Amateur and professional golfers display somewhat different injury patterns. Injuries to the nondominant wrist and to the lower back are common in both groups (10). Amateur golfers have a higher incidence of elbow and shoulder injuries than professional golfers (2). Male professional golfers experience more injuries to the left shoulder than their female counterparts, while female professional golfers have more injuries to the left wrist than male professional golfers have (11). Regarding elbow injuries, lateral elbow pain occurs at a much higher frequency than medial elbow pain in amateur golfers, whereas professional golfers have a similar incidence of medial and lateral elbow pain.
As with the shoulder, the nondominant hand and wrist are most commonly injured. While most injuries of the hand and wrist are overuse injuries, the wrist and hand is the most common acutely injured body segment in golf (15). Generally, acute injuries occur when striking the ground, a root, or tree on follow-through, or in thick weeds. Hook of the hamate fractures are not uncommon in golf, similar to those seen in baseball, occurring due to both acute and chronic stress injury (3). DeQuervain's disease of the nondominant wrist is seen in golfers. Some authors relate this to the ulnar deviation of the nondominant wrist that occurs at impact (12). Other tendinopathies that have been reported in golfers include the flexor carpi radialis and extensor carpi radialis. Older golfers also are at risk for osteoarthritis of the wrist and hand, including the first metacarpal-trapezium joint.
Injuries to the shoulders primarily involve the nondominant shoulder (7). At the end of the backswing, the nondominant shoulder is horizontally adducted and internally rotated, a position of impingement that also stresses the acromioclavicular joint. Rotator cuff injuries are common in golf and are generally chronic in nature (8).
Golf-related back injuries include soft tissue injuries (acute and chronic muscular strain, muscular spasm), acute disk injury, and exacerbation of the myriad causes of back pain unrelated to golf. Countless hours on the driving range allow most professional golfers to hone and maintain smooth, efficient swings but also are a risk factor associated with overuse injuries. Professional golfers have the highest incidence of back injury of all professional athletes (14). Frequently, sedentary golfers have limited strength, endurance, and/or flexibility. The inefficient and sometimes violent swings of these golfers may result in acute or repetitive trauma to these weak, tight structures. "Overswinging" occurs when brute strength is used to compensate for biomechanical inefficiencies in "weekend golfers'" attempts to hit prodigious drives. Unfortunately, these attempts usually involve intemperate effort rather than a well-coordinated, athletic movement, and also can cause injury. During the golf swing, amateur golfers generate 80% greater torque and shear loads than those produced by professional golfers (7). These loads have been implicated in disk injury.
Treatment of injuries in golfers involves the same techniques used in other athletes. The exquisite timing and coordination required for an elite swing is vulnerable to maladaptation to accommodate injury, and can be difficult to reestablish. For this reason, one must be cautious when advising an injured competitive golfer to "work through" a painful swing. Swing changes may cause improvement or worsening of scores, and much thought must go into the decision to make a conscious change in swing technique. However, evidence exists that adapting swing technique can allow resolution of chronic back injury in the elite golfer (5). Because improving the biomechanical efficiency of the golf swing can result in better shots and a smoother, less physically stressful swing, advising golfers to seek advice from a teaching professional will enhance success of a treatment program. Advising the golfer to work on less physically demanding shots, such as putts and chips, while an injury heals will result in better play when they are ready to resume playing matches and results in a less frustrated patient. Be aware that although putting is not physically demanding, the posture required to putt is stressful to many lumbar spine injuries.
Return-to-play issues are influenced by the same principles considered when advising athletes in other sports. Functional range of motion, strength, and endurance and the emotional readiness of the athlete must be assessed (6). A progressive return-to-play starting with putting, chipping, and pitching followed by advancing through longer clubs using the full swing has been recommended (1).
Provision of medical services during a golf tournament presents unique challenges compared with other mass spectator events and is more similar to marathon or road race coverage than stadium- or arena-based mass spectator events. Bleacher seating is available near some holes, but fans are allowed to walk around the course. Over a 4-d PGA tour event, each round starts early in the day and frequently lasts until the late afternoon or dusk. This exposes fans to prolonged contact with environmental conditions and, in some cases, prolonged consumption of alcohol. Golf courses typically cover more than 100 acres, and fans may be situated nearly anywhere on the course, so access to all parts of the course is necessary to provide adequate care. Weather-related injuries are common, especially heat injuries on hot days.
When planning for mass-spectator events, it is advisable to have a medical area staffed and equipped to handle minor emergencies in order to avoid overwhelming local emergency facilities. The medical team should consist of physicians, nurses, certified athletic trainers, emergency medical technicians, medical assistants, clerical staff, and others as needed. If large crowds are anticipated, more sophisticated capabilities should be provided. Many summer events are crowded with deconditioned individuals. Arranging for a dedicated medical communications network and mobile response teams on bicycles, golf carts, or other methods is advisable if large crowds are anticipated. Automated external defibrillators should be available at strategic locations or rapidly available via mobile carts to the far reaches of the course. Having areas for emergency cooling and oral and intravenous fluid resuscitation is advisable when large crowds are anticipated in hot, humid weather. Emergency transport for people who are too numerous or too severely injured or ill to be managed onsite must be planned in advance.
Unfortunately, there is a paucity of data regarding the types, incidence, severity, or other details of injuries observed at large golf events. Likewise, there is little literature describing details of medical coverage provided at these events. In the one published survey of medical coverage of PGA Tour events, Ma et al. found that a variety of providers were present at 97% of tour events (9). These included physicians, nurses, emergency medical technicians, and paramedics, with at least one Advanced Cardiac Life Support (ACLS)-certified provider with ACLS equipment. Ambulances were onsite at 89% of events. Fan fatalities have been reported at PGA Tour events. Ma indicated that three fan fatalities were reported at 36 PGA Tour events (4), although causes of death were not reported.
More golfers die from being struck by lightning than participants in any other sport other than fishing, and in some years outnumber fishers, despite fewer participants (4). Weather is a variable that can be planned for but not controlled. It is important to establish a weather policy in advance of competition. Some courses are equipped with lightning detection systems. The old adage "If you hear it, clear it" is conservative but wise, as lightning is typically most intense along the leading edge of the storm.
Death by lightning has occurred among spectators at PGA Tour events, so contingencies must be made with these possibilities in mind whenever large crowds are anticipated at a golf event. Lightning can travel as far as 10 miles in front of or behind a storm, so waiting for rain is foolhardy. Lightning detection systems are advisable when large crowds are expected. Lightning detection systems are installed at many golf courses, and portable lightning detection systems also are available, which can be rented for courses that do not have permanently installed systems. Typically, sirens or airhorns are sounded to warn competitors and spectators about potential lightning and to suspend play. Competitors and spectators should be advised of proper precautions to take when lightning is a threat. Avoiding open areas, single trees, power lines, bodies of water, golf carts, clubs, and umbrellas are important safety strategies. Clubhouses, protected shelters, and closed vehicles are the best options. Courses vary in the protection afforded to players. When large crowds are anticipated, plans for orderly evacuation of the course should be made in advance and evacuation information provided in the form of signage and/or information provided in the event program. Some events provide buses at locations around the course for temporary shelter during storms. For courses and events without lightning detection systems, the old adage regarding thunder and lightning is proposed as a guideline: "If you can see it, flee it; if you can hear it, clear it." An excellent review of lightning safety and treatment of lightning injury has been published in Annals of Emergency Medicine (16). Most fatalities from lightning strikes occur due to cardiac arrest, so ACLS protocols should be followed, with rapid defibrillation a key goal in resuscitation. Those who survive a lightning strike without cardiac arrest generally survive but must be followed closely for neurologic injury. Contrary to popular belief, lightning victims are not "charged," and resuscitation should be immediate without fear of being electrocuted by the victim. However, care should be taken to remove the victim and rescuers to safe shelter from further lightning strikes. Lightning victims should be evaluated for injuries related to falls or barotrauma that can occur close to a direct lightning strike, including neurologic, musculoskeletal, and internal injuries. Neurologic injury is typically the most profound long-term injury sustained by lightning victims. Information about lightning injury and prevention can be found at a Web site sponsored by the National Atmospheric and Oceanic Administration, www.lightningsafety.noaa.gov (13).
Medical care for athletes involved in high-level professional competition is provided in a secure area, away from the general public. Physical therapy trailers are available at PGA, Champion's Tour, and Ladies' Professional Golf Association (LPGA) tour stops, which are staffed by physical therapists, chiropractors, and certified athletic trainers. As the overwhelming majority of injuries among highly competitive golfers are overuse injuries, medical facilities emphasize treatment of these types of injuries over evaluation of acute injury.
Golf events, like golfers, come in all sizes and forms. The care of the golfer involves the customary approach to sport-related injuries: making an accurate diagnosis, maintaining or restoring musculoskeletal and cardiovascular functioning, and providing sport-specific assessment and conditioning. Return-to-play is driven by degree of recovery, emphasizing the health and safety of the athlete, and can be enhanced by professional instruction.
The level of medical coverage provided at golf events is related to the number of anticipated participants and/or spectators, weather conditions, access to local health care facilities, and tournament resources. If large crowds are anticipated, greater resources are necessary to provide adequate onsite medical coverage and avoid overwhelming local emergency facilities. A formal lightning safety policy should be an important part of preevent planning when large crowds are predicted.