The Forever Fairway: Strategies for life long golf without pain or injury
Dr Ronan Kearney

I am a Consultant Sports and Exercise Medicine Physician primarily based at the UPMC Sports Surgery Clinic in Santry. I also work across several different sports, but at the moment, I am in the high-performance centre in Sport Ireland and looking after athletics, preparing for the Paris Olympics. I have also worked for DP World Tour Golf and Legends Tour events. I also do a bit of work in the GAA and am a senior clinical lecturer at Trinity College.

I spend most of my time in the UPMC Sports Surgery Clinic, which is made up of the main hospital and the Sports Medicine Department. The Sports Medicine Department is made up of a team of Sports Medicine Consultants alongside a full MBT of specialists, physiotherapists, and strength and conditioning coaches. We work in tandem with our rheumatology and radiology colleagues in the main hospital.

Working in golf is very rewarding and I hope that some of the things I have learned in elite golf I can share with the recreational golfer also. Worldwide 60 million people play golf in 206 countries so huge participation sport. As you age previously accessible activities can be more challenging. Golf, however, is a more popular sport for the older adult and it is a really important form of exercise as we age. Golf in itself is a recipe for lifelong health.

These are some nice infographics that the DP World Tour has published and they did a lot of work in terms of public health and the benefits of golf overall so physical inactivity causes over 3 million deaths worldwide per year and golf is a phenomenal form of activity in its own right.

Research has long proven that the more physically active we are the greater we live in terms of time. More specifically the health benefits of golf reduce your risk of multiple medical issues like cardiovascular disease, diabetes, stroke, colon cancer, breast cancer and dementia can be reduced by up to 33%. There is a reduction of 65% in hip fractures in golfers as well so huge benefits to be gaining. A Swedish study found that golfers have a 40% lower mortality rate than non-golfers.

Anyone who plays golf also understands that the physical and mental health factors are so beneficial. It is proven that there is a boost in self-esteem and a reduction in depression.

Golf is associated with a higher risk of skin cancer, so anyone who golfs should make sure to get their skin checked on a regular basis and use sun cream. We share this with professionals on the DP World Tour to remind them, but it also applies to recreational golfers in terms of skin care.

Golfers can develop a number of musculoskeletal issues that may or may not be related to the sport itself, and that is where we, sports and exercise medicine physicians, can help. We have to keep you as active as possible and on the course for as long as possible so that you achieve all those health and social benefits that we all know golf brings.

What are the common issues that we might be able to help with?

A recent study looked at the injuries in both amateur and professional golfers and as you can see the most common injuries in golf are elbow, lower back, hand/wrist, and shoulder. Life-long golf can most definitely be cut short by injury so appropriate management of such injuries is essential to getting you back on the course. The purpose of today’s talk we will focus on the amateur’s two most common injuries lower back and elbow.

Lower back pain makes up 16% of amateur golfers injuries and about 41% of professional golfers injuries more likely to be in professional golf due to the larger forces in it and the larger repetitive load placed on the lumbar spine with professional golfers hitting 100’s of golf balls a week generally.

Several modifiable factors can reduce your risk of lower back pain while playing golf. These are a reduction in BMI, poor strength, flexibility, and coordination. Certain swing biomechanics lead to lower back pain, and we also know that carrying a bag can increase your risk of having lower back pain while playing golf.

The golf swing is considered one of the most difficult movements in sports and to perform a golf swing a powerful movement is required with rapid rotational forces being transferred to the golf ball with lots of compressive load placed on the lumbar spine, calculated to be about 7 to 8 times body weight.

Recreational golfers have different variations in swing and muscle activation during the golf swing itself. We know that older golfers age related muscle changes their swing and 3 typical swings have been associated with lower back pain. The early extension is where our hips come forward to the hand space during the swing. A reverse-C finish puts a greater load on the lower back structures. The reverse spine angle is an over-extension of the lumbar spine during the backswing.

I’m not going to get too mechanical but certain swing mechanics are more common in those with backpain so it is really important for those mechanics to be identified and to work closely with your golf professional to address these issues in your swing as part of the management of your injury. Other potential modifiable factors include flexibility.

It is obvious that strength plays a large part in both the prevention and management of golfing injuries and the professional game itself has transformed over the last decade with most top professional golfers putting a large emphasis on strength and conditioning as it reduces the risk of injury and improves performance, this can also be applied to the recreational golfer.

To get to the root of the problem in lower back pain you need to have a full assessment so a clinical assessment, strength assessment, flexibility assessment and biomechanics assessment and sometimes imaging if it is necessary.

To manage lower back pain in golf, really if we take a general approach here education will form a huge part of that so in terms of making sure that you are aware of what you need to do to improve your symptoms.

Weight loss can form part of the management we spoke about muscle strengthening and muscle exercises as well as flexibility exercises which can also be helpful. Looking at your swing biomechanics can be helpful also to have your golf professional assess that as well.

We are lucky enough at the UPMC Sports Surgery Clinic to have options to secondary management which is not always needed but is helpful at times to create a window opportunity where pain doesn’t progress into exercise rehabilitation.

The second most common injury in golf is the elbow and it is often an overuse injury more common in females. Unfortunately, the term tennis elbow is associated with tennis but it is more common in golf.

Risk factors for developing elbow pain in golf can be due to hitting too many balls in too short a time. The grip may be too tight or, you may be hitting the ground before the ball or if you try to change your swing very gradually without increasing the load. Often, we will see wrist flexion changes at the impact of the golf ball that can lead to different loads placed on the elbow.

The wrist flexor burst at impact is to try and increase clubhead speed but can lead to some additional forces placed on both the outside the lateral and the medial lead and trail elbows. The problem with golfers who have wrist pain is the wrist position and impact is assessed. There can be several different causes for elbow pain in golfers that would need to be assessed as we said inside a golfer’s elbow is a medial epicondylopathy and outside elbow pain is often lateral epicondylopathy.

To truly determine the issue, you will need a full clinical, strength, flexibility, biomechanics, and, at times, imaging assessment.

Management for elbow pain depends on the diagnosis itself but generally consists of education about your problem, strength-based rehabilitation, biomechanics, and, again, coming back to that golf-specific rehabilitation. Some aids can be a support brace or maybe even increasing your grip size. Again, all of this will depend on the injury itself.

Management options that can be helpful for elbow-related pain in golfers include ultrasound-guided injections, platelet-rich plasma, corticosteroid, and, at times, extracorporeal shock wave therapy.

What is Extracorporeal Shockwave Therapy (ECSWT)? It is a shockwave that works by acoustic shockwaves which carry energy to different tissues. These shockwaves can trigger tissue responses which have many beneficial effects such as pain relief, and increased blood flow and when needed can disrupt calcium deposits in tissues. The combination of these effects can lead to improved muscle recovery.

What is Platelet Rich Plasma (PRP)? It is a form of regenerative medicine that harnesses the body’s ability to try and increase natural growth and has healing factors to try and improve injury recovery. The blood is taken as it would during a simple blood test spun in a centrifuge and then the PRP portion which contains concentrated healing cells is injected into the targeted tissue. PRP has less side effect profile than traditional corticosteroid injections and some cases show they are proven to beat steroids in the long-term musculoskeletal conditions.

You have managed your golfer’s elbow and you are trying to ensure you have lifelong golf like we initially spoke about. Performing a warm-up means you are less likely to get injured playing golf. Injury is 3 times more likely in recreational golfers without a warm-up, here are some of the pre-round warm-ups recommended by the UPMC Sports Surgery Clinic. I recommend you take a copy of this and bring it into your pre-round routine.

You will often see professionals preparing for a round hours in advance when most of the time we are rushing out of the car to get to the first tee. How many times has it taken you 2 or 3 holes before your body is ready to swing a golf club. Try and go earlier to the golf club and spend 10-15 minutes warming up.

There have been a few questions ahead of today’s talk regarding osteoporosis and golf. I suppose osteoporosis is a condition that means your bones are below bone mineral density and are at an increased level of fracture. We can make a diagnosis with the help of DEXA scanning. It is in approximately 20% of females and 6% of males over 50 years of age in Ireland. It is vital that those with osteoporosis manage it properly often with the help of your doctor and rheumatologist.

Resistance exercise plays a huge role in the treatment of osteoporosis and really should be guided by your professionals. While golf is considered low impact, individuals with osteoporosis should discuss with professionals if they should participate. It is crucial to understand the persons overall health status, bone density, pain levels and functioning strength abilities before having that decision.

I look after a number of golfers with osteoporosis and there is a number of different tips in terms of the golf swing that can reduce their chance of further injury.

Firstly, working closely with their golf professional to ensure that their golf swing is a good technique. At times rotating your lead foot to improve movement through the hip externally. Shortening the backswing can reduce that bending stress in the lower back. Even something as simple as standing closer to the ball can reduce that forward bending and reduce the bending of the lower back. There is a number of different mechanical tips and tricks that can reduce your lower back stress especially if you have lower back stress, osteoporosis can allow you to continue to golf in the future.

In summary, strategies to improve lifelong golf among recreational golfers include really a holistic approach that includes appropriate management of medical issues and injuries.

Exercises to improve strength and flexibility that act as both health and performance boosters as well as injury prevention.

Working alongside a knowledgeable golf professional to help identify any swing biomechanics that may lead to future injury. Ensure an appropriate warmup prior to playing and most importantly have fun golfing.