A Guide To Preventing And Managing Golf Injuries
Over 25 million Americans play golf on a regular basis.1 Unlike many athletes, golfers also remain active well into their later years.2 With the aging of the adult population, increasing numbers of seniors will turn or return to golf for exercise and pleasure. Given the increasing numbers of people playing golf, you may start to see more patients presenting with golf-related injuries. Golf-related injuries are commonly attributed to the repetitive nature of the golf swing and a long day of walking and standing.3,4 One may also see an increased incidence of overuse injuries among senior golfers. These injuries may be partly due to the mechanical circumstances of an aging “more-upright” swing, antalgic gait patterns and the influences of joint replacements. The prevalence of injuries among amateur golfers reported among all epidemiologic studies ranges from a high of 62 percent to a low of 23.3 percent.3,5-7 Surprisingly, when rates of injury per golfer per year are considered, the rate of injury for each of these studies is nearly identical and ranges from 1.19 per golfer per year to 1.31 per golfer per year.5-7 In a study of 198 amateur golfers, researchers estimated that over 32 percent of injuries were localized to the low back and lower extremity.8 In a similar study of 393 professional golfers, over 37 percent of injuries were localized to the low back and lower extremity.4 Golf injuries can be categorized as single traumatic events or overuse injuries. Numerous circumstances and events, ranging from technical errors and physical deficiencies to a lack of practice warm-up and environmental conditions, have been linked to golfing injuries.8,11,17,19 While common rehabilitation efforts include rest, physical therapy, ice, medicine, injections, heat, bracing and surgery, it’s important to understand the biomechanical issues (specifically, the swing mechanics) involved in golfing in order to provide appropriate treatment. Understanding Swing Mechanics Effective swing mechanics including proper set-up, backswing, downswing and follow-through are dependent upon a stable base of support, flexibility, strength, balance and proprioception. Aside from compensating for shoes or environmental circumstances and dampening shearing forces at the foot-ground interface, the lower extremity facilitates weight shift, sagittal and frontal plane positioning, and transverse plane rotation. The lower extremity also sets the stage for hip “low-gear” and shoulder “high-gear” rotation and stability while minimizing unnecessary oscillations. Williams, Cavanagh and Carlsoo have shown that ground reaction forces (GRF), including the direction and magnitude of shear forces, exhibit distinct differences between right and left feet.9,10 Koslow examined weight shift patterns among 30 beginning golfers using an 8-iron and driver, and reported that most did not execute proper weight shift.11 Swing patterns appear to be very individualized and do not always adhere to prescribed patterns, especially among mid- and high-handicap golfers.11,12 Researchers have shown that optimizing patterns of rotation and weight transfer will facilitate the segmental and kinematic linking necessary to perform an efficient, accurate and reproducible golf swing, resulting in a lower risk of injury.9,13 All body segments contribute to the effective movement of the body’s center of mass during a typical golf swing, none moreso than the lower extremity. Every great swing has a starting point or setup, which places the golfer in an optimal position to execute a reproducible golf swing and ball impact. This position has been described in great detail but simply represents a comfortable ready or athletic position. Ideally, the subtalar joint is nearly neutral or in a slightly pronated position. When this occurs, the golfer is set in a relatively relaxed and stable position that requires little energy to maintain. Also keep in mind that the feet initiate backswing. Subtle shear forces build within both feet, resulting in a net movement away from the intended target.9 A kinetic linkage triggers a “low-gear (hip)/ high-gear (shoulder)” rotation. This creates a smooth takeaway and serves to store kinetic energy for later release at impact. Once the rotation has been triggered, the feet promote a stable base for rotation with the golfer maintaining centers of pressure in the mid-part of the golf shoes throughout back swing and only shifting forward in the leading foot at the top of the backswing. Shearing forces, on the other hand, tend to build and follow the rotation pattern of the golfer. These shearing forces accumulate in the anterior medial aspect of the leading foot and the lateral aspect of the trailing foot at the top of the back swing.9 Improper weight shift and the failure to maintain center of pressure near the mid-point of the golf shoe challenges the golfers’ ability to “square up” the club face at ball impact. Pertinent Points On Downswing And Follow-Through During the downswing, the club head drops through an arch of rotation, gaining speed and momentum as it prepares to transfer previously stored kinetic energy to the ball at impact. “Low-gear” rotation of the hips initiates the downswing while the nearly simultaneous “high-gear” rotation of the shoulders and arms creates the club head speed. The feet and lower extremities serve to support “low-gear” hip rotation and promote stability. At impact, weight shifts toward the intended target, the center of pressure shifts forward and the shearing forces peak in the leading shoe.9 Also be aware that unstable shoes or improper orthoses will contribute to failure of the shoe and orthoses to resist excessive lateral overload. This can contribute to the appearance of the reverse-C position and may lead to inconsistencies at impact. Follow-through permits the golfer to safely decelerate the swing and dissipate the rotational forces. Weight shift and shearing forces load the leading foot laterally as typical loads reach 85 percent of body weight.12 The trailing foot follows hip rotation as the golfer pivots upon the forefoot, shifting his or her weight forward with the center of pressure concentrated in the forefoot.11 The events of follow-through can create excessive laterally directed shear forces. These forces can lead to a laterally deviated center of pressure leading to lateral column overload. These forces can also contribute to excessive external rotation of the leading leg and knee with increased potential for damaging hyperextension of the knee. In order to treat golf-related injuries successfully, one must not only arrive at an accurate diagnosis, but it is also important to identify the circumstances that aggravated or initiated the injury. This allows you to better identify contributing factors and establish a program for treatment/recovery. With this in mind, let’s consider the following cases that combine podiatric care with chiropractic/manipulative treatment. Case Study One: When A Patient Has Persistent Heel Pain A right-handed female golfer with a mid-handicap presented with moderate right inner heel pain, which had adversely affected her golfing activities for the past three months. She described morning and post-rest dyskinesia. The patient noted that she had poor tolerance to prolonged walking and standing, and could not walk further than 200 yards without the onset of moderate pain. She also described stiffness throughout her backswing and pain during her downswing and follow-through. The patient related a history of mild intermittent low back pain that specifically affected the right buttock and sacroiliac (SI) joint. She said the problem had been persistent for the past six months but the mild pain had not caused her to pursue treatment. Pain was localized to the proximal one-third medial and central bands of the plantar fascia and to the medial calcaneal tubercle. The patient had a thickened proximal portion of the central band of the plantar fascia. Upon a biomechanical examination, we noted that she had a 4-degree flexible forefoot valgus bilaterally. When the patient was in a relaxed calcaneal stance position, the right heel was everted 5 degrees while the left heel was everted only 3 degrees. The patient’s gait demonstrated an obvious midstance and propulsive phase pronation of the right foot, with an abducted forefoot and prominence of the talonavicular joint complex. When we observed her swing mechanics, it was clear that she had an exaggerated setup with the frontal plane of her knees being too far forward. She also never adequately achieved a ready position and improperly shifted her weight at ball impact through follow-through. This was best observed as a delay of heel lift at ball impact which carried through into her follow-through. During the standing postural exam, we noted that the patient’s right shoulder was depressed and there was asymmetry of ASIS and PSIS. We estimated that her right lower extremity was 3/8-inch longer than the left limb. The chiropractic examination corroborated the finding of a right leg length discrepancy of 3/8 inches. While there did not appear to be a true anatomical deficiency, the presence of moderate sacroiliac (SI) joint fixations/dysfunction suggested that the observed leg length discrepancy was most likely functional in nature. Using motion palpation, the chiropractor assessed the SI fixation. This type of palpation is commonly performed by chiropractors and can be defined as a dynamic palpation through a passive and functional range of motion at the suspect joint complex. The chiropractic exam noted mild tenderness over the dorsal sacral ligament on the right side of the sacrum and also detected muscle adhesions over the medial aspect of the mid-section of the gastrocnemius muscle belly. Providing A Combination Of Podiatric And Chiropractic Treatment As far as the podiatric treatment goes, we focused on reducing the soft tissue inflammation with typical modalities such as ice, ice/massage, phonophoresis and NSAID therapy. The patient was able to enhance her range of motion with stretching. In order to address her pathomechanics, we applied a temporary low-dye strapping, emphasized functional foot orthoses and recommended new golf shoes. For the orthoses, we started with a neutral impression cast that was intrinsically balanced to 4 degrees of inversion on the right and 2 degrees of inversion on the left. The positive casts incorporated a 2-mm medial heel skive bilaterally and a minimum plaster fill. The heel width was based upon the standing heel width in order to minimize the potential for soft tissue impingement.14,15 The resulting orthoses were fabricated from a semi-rigid material with a wide shell that incorporated a deep 20-mm heel cup and a lateral flange tapered to the styloid process. This helps to promote greater proximal stability to the rearfoot. We incorporated a flat no-motion and elongated EVA heel post that was not beveled laterally, and proceeded to select an appropriate top cover material. No heel lift was introduced since the observed limb length discrepancy was thought to have a functional origin. We also referred the patient to a chiropractor for evaluation and manipulative management. Chiropractic treatment included manipulation of the involved SI joint to normalize pelvic motion and minimize distal compensations. Also keep in mind that manipulating the involved SI joint can produce a favorable reduction of referred pain into the calcaneal region by minimizing sclerotomal pain pathways. Sclerotomal pain patterns tend to follow bony tissues and can be described by the patient as deep, dull aching pain that is hard to localize. In the foot, the chiropractor addressed the fascial adhesions of the central band with deep massage using the Graston Tool®. While common massage techniques can be effective for decreasing fascial adhesions within the plantar fascia, there is growing evidence that the Graston Tools® (six different contoured stainless steel tools manufactured with beveled surfaces for patient comfort) can be more effective in reducing adhesions. Lastly, the chiropractor implemented a soft tissue technique known as Active Release Technique® to address the muscular and fascial adhesions in the gastrocnemius muscle. Case Study Two: When The Patient Has A Combination Of Cuboid Syndrome And Peroneal Tendonitis A right-handed male golfer developed lateral left foot pain after teeing off at a long eighth hole. He described an instantaneous sharp pain that was followed by moderate aching pain with each step. He was unable to finish his game. He continues to feel lateral foot pain that is aggravated by climbing stairs, walking on uneven terrain and during golf practice swings after six weeks of rest, NSAID and message therapy. Previous radiographs were negative for fracture but he describes a past history of multiple sub-acute ankle inversion injuries that occurred when he played racquetball. While the patient’s ambulation appeared to be normal at first glimpse, we noted that he was unable to adequately invert his left rearfoot during the mid-stance and propulsive phases of gait and remained pronated through both phases. The patient experienced pain but the exam detected no crepitus upon deep palpation of the plantar aspect of the cuboid. We also palpated proximally along the peroneal longus tendon to the peroneal tuberical and detected no crepitus. While the grade of muscle strength was generally normal (5/5) for most extrinsic muscles, we were able to elicit pain and weakness (4/5) when resistance to the peroneal longus was matched by a dorsiflexion force applied to the first metatarsal head. The chiropractic examination revealed trigger points along the peroneal longus muscle.16 Upon gentle palpation, the chiropractor elicited pain that referred to the area of the lateral foot. When the chiropractor applied a gentle distractive motion palpation, the motion of the subtalar joint revealed a decrease of normal axial distraction. As per our previous observations, the chiropractor found a tender calcaneal-cuboid articulation that exhibited diminished joint motion consistent with a chronically pronated left foot. Making Recommendations On Golf Shoes And Orthotics Golf is a sport that consists of multiple complex and often conflicting movements that culminate with the advancement of the ball. Golf shoes serve as the link between the foot and the supporting surface, no matter the environmental circumstances. A well-designed golf shoe should have a slight forefoot rocker sole to permit the development of an easy stride. The outsole should be continuous and provide good traction while the cleat pattern enhances stability on a variety of surfaces without inhibiting weight shift. One should incorporate a raised heel in order to promote ease of walking and facilitate a comfortable set up position. The heel should also be continuous with a gentle taper to the forefoot. The outsole and midsole should divert excessive lateral forces back more centrally without inhibiting the elevation of the medial side of the shoe during backswing or follow-through. The heel cup should be stiff and extend far enough laterally to support the calcaneal cuboid joint. The shoe’s midsole and upper should resist excess lateral torque and divert excessive lateral force. The toe box should provide adequate room to avoid crowding of toes and accommodate minor structural abnormalities. The upper should be breathable and resistant to abrasions. It should also resist excess moisture accumulation that may be picked up during a morning’s walk on dew covered greens. Unfortunately, there is very little available data on using orthoses to treat lower extremity injuries among golfers. However, it is widely recognized that orthoses can augment the recovery from lower extremity injuries or complaints. Stude and Brink saw improved trends of balance and proprioceptive symmetry among a group of experienced golfers following a six-week conditioning period of using flexible orthoses.17 Herring and Davey documented significant improvements to golfer performance skills when the golfers used golf-specific orthoses.18 When prescribing orthoses that are intended for use during golfing, you should carefully consider features that will augment a natural walk but also aid the golfer in developing an effective pattern of weight shift. Minimal positive cast fill, deeper anatomically appropriate heel cups and wide shells fabricated from semi-rigid materials can help ease golfers into using foot orthoses. Key Treatment Essentials We took steps to stabilize the cuboid and relieve the peroneal tendon. We continued with NSAIDs, introduced iontophoresis with dexamethasone sodium phosphate 4 mg/mL and emphasized strapping. We found that a modified ankle high, open basket-weave strapping most effectively contained the peroneal longus and maintained the foot in an everted, abducted and dorsiflexed position. We encouraged the patient to wear a more stable athletic shoe and subsequently employed a prescription foot orthoses. We created a neutral impression cast, which was intrinsically balanced to 2 degrees of inversion. The resulting positive cast incorporated a 4-mm medial heel skive on the left and a 2-mm skive on the right. Employing a minimum fill and heel expansion based upon standing heel width minimized the potential for soft tissue impingement.14,15 We again used a wide, semi-rigid functional orthoses that incorporated a deep 20-mm heel cup and a lateral flange tapered to the styloid process to enhance stability and promote proximal support to the rearfoot. We also added a flat, elongated and no-motion EVA heel post laterally. We attached a 3-degree extrinsic forefoot valgus sulcus extension and attached a top cover of an appropriate material. We subsequently referred the patient to chiropractic care for an evaluation of the patient’s lower leg pain and weakness. Chiropractic care included manipulating the foot in order to increase the normal subtalar and talocrural joint play in axial distraction, and facilitate normal supination of the cuboid on the calcaneus. The chiropractor also performed the aforementioned Active Release Technique® over the muscle belly of the peroneus longus in order to decrease the lateral foot pain. Given the patient’s history of inversion sprain, the chiropractor used the Graston Tool® to gently minimize the adhesions in the anterior talofibular ligament. Doing so can facilitate greater talocrural range of motion. Getting Results Both golfers quickly returned to full activity without any further pain or dysfunction. When contemplating a return to activity for patients who golf, one should not only address the patients’ physical and biomechanical deficits, but emphasize to patients the importance of better preparation to play the game. For example, spending time with a golf professional to review, re-learn and practice proper swing mechanics can reduce the likelihood of re-injury. When one can minimize physical deficiencies and technical errors, and use appropriate equipment, golfers can anticipate years of injury-free golfing with improved performances. Dr. Herring is a Diplomate of the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. He is also a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, and the American Academy of Podiatric Sports Medicine. He is a team podiatrist for several college and professional teams, and has a private practice in Spokane, Wash. Dr. Pearson is a Diplomate of the American Board of Chiropractic Orthopedics and is a Fellow of the International College of Chiropractors. She is a team chiropractor for the Gonzaga University Bulldogs and has a private practice in Spokane, Wash.
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