Foot and ankle injuries that happen during golf activities can occur from traumatic events but are more likely to occur from overuse type injuries. Having practiced in a golf resort and retirement community for over 20 years, I have seen many different overuse injuries that could be directly related to the mechanics of the golf swing.
In personal discussions I have had with Ken Crow, the Director of Golf Instruction at the Pinehurst Resort and Country Club in Pinehurst, N.C., the golf swing can be broken down into the following phases: set up, takeaway, downswing, impact and follow-through.
At set up, the weight should be evenly distributed on both feet with slightly more weight on the inside of the balls of the feet. During the takeaway or backswing phase, the front foot should pronate, placing more pressure on the inside of that foot while the back foot stays stable as it receives more weight. The front foot heel may come off the ground and place more pressure on the ball of that foot. This is necessary to promote a full shoulder turn.
During the downswing, weight rapidly shifts to the front foot until impact when the weight should be evenly distributed between the feet again. There is a lateral shift of the hips and knees during downswing that continues through impact and will continue slightly into the follow-through phase. During the follow-through phase, the front foot supinates and the back heel comes off the ground with the weight of the back foot being placed on the big toe.
What The Literature Reveals
There is little published on lower extremity golf injuries. Campbell describes multiple golf injuries with the back and the elbow being the most common areas injured.1 He does not mention any foot or ankle injuries. Foster cites back and upper extremity injuries, but does not include any lower extremity complaints in his list of top 10 golf injuries.2
In their review of golf injuries and treatment, Herring and Pearson state that injury rates per golfer per year range from 1.19 to 1.31 with 37 percent of those injuries occurring in the low back or lower extremity.3 They presented a case study of one patient with heel pain who was treated with a combination of podiatric and chiropractic care. Daniels states that the most common golf-related foot injuries he sees are heel pain, metatarsalgia, Morton’s neuroma and tendonitis.4 He says these injuries are caused by increased motion of the foot. A study by Stude and Gullickson found that orthotics can increase balance and allow golfers to drive the ball farther.5
How To Recognize And Address Intermetatarsal Neuromas
The most common golf-related complaint I see is an intermetatarsal neuroma. It typically occurs in the third interspace and is almost always in the non-dominant foot. In other words, if the golfer swings the club right-handed, the neuroma occurs in the left foot and vice versa. This occurs due to the repetitive force placed on the nerve between the metatarsals as the momentum of the golf swing causes the forefoot to invert at the end of the golf swing.
The irritation of the nerve is more noticeable on longer shots such as a drive and is imperceptible on shorter shots like putts. As the forefoot inverts and the rearfoot supinates, the common interdigital nerve gets irritated within the third innerspace. This nerve unit then enlarges due to the irritation and the classical neuroma symptoms develop. These symptoms include burning, numbness and shooting pain into the toes.
The treatment options for this problem are the same as for any neuroma. They consist of NSAIDs, corticosteroid or alcohol sclerosing injections, orthotics and surgical intervention. One important treatment goal is to adjust the mechanics of the swing to decrease the inversion and supination of the foot. A 45-degree abduction of the front foot during ball address will decrease the inversion at the end of the swing and decrease the mechanical irritation of the nerve. Most of these golf-related neuroma cases resolve with a simple change in stance and minimal other treatment.
What About Extensor Tendinitis?
Extensor tendinitis occurs only with the driver of the golf cart and I have seen it occur only in the right foot. I have named this entity “golf cart tendinitis” as it typically will happen after playing rounds on hilly golf courses when the driver uses the parking brake excessively.
The brake pedal on a golf cart is made in two pieces. The top piece is the parking brake and the driver has to depress this downward in order to engage the brake. The motion of depressing the parking brake can cause a strain on the extensor digitorum longus tendons. This repetitive strain causes irritation of those tendons and a tendinitis develops.
Symptoms usually include diffuse dorsal pain. Upon examination, there is typically pain with palpation of the extensor digitorum longus tendons and some forefoot swelling. There is typically no pain with palpation of the lesser metatarsals or metatarsophalangeal joint motion.
Treatment options for this condition are the same as the treatment for any other cause of extensor tendinitis. They consist of elimination of the irritation to the tendon, NSAIDs, corticosteroid injections and immobilization. I have never had to operate for this condition and have not seen a rupture of the tendons.
Discussing the cause of the irritation with the patient is imperative. I encourage patients to alternately use the left and right feet on the brake, and have counseled them to seek flat areas on which to park the golf cart. Using the heel to depress the parking brake can also eliminate strain on the extensor tendons.
When Lateral Ankle Pain Occurs
Lateral ankle pain occurs due to the excessive motion of the rearfoot during the golf swing follow through. The forces applied to the lower extremity during the follow through cause an abduction of the knee of the non-dominant limb and a supination of the foot on that side with eversion of the rearfoot. On longer shots, such as a drive, this force can strain the ankle ligaments and peroneal tendons to the point where they cause pain.
Repetitive strain will cause laxity of the lateral ankle ligaments and predispose that ankle to easier spraining.
Symptoms include lateral ankle pain and lateral midfoot pain. Some swelling may occur. Rarely will bruising occur. The examination usually indicates lateral ankle ligament laxity and diffuse pain on palpation of the lateral ankle ligaments and peroneal tendons. Talar tilt and anterior drawer signs are rare.
Treatment consists of stabilizing the ankle either with a compression ankle brace or a functional stirrup type ankle brace. An orthotic is often useful to control subtalar and midtarsal joint motion. A custom “Richie” type brace may be necessary if there is instability in the ankle. NSAIDs and occasionally corticosteroid injections are helpful to decrease inflammation on the area. Rarely is surgical intervention necessary to stabilize the lateral ankle ligaments. Mechanically, one can reduce the risk of lateral ankle pain by abducting the front foot toward the target and away from the midline of the body in the stance position when the golfer is addressing the ball.
Addressing Hallux Subungual Hematoma
This condition occurs when the golfer applies excessive pressure to the big toe during the golf swing. Typically it will occur at the end of the follow through and will only happen on the dominant foot. In other words, if the golfer swings right-handed, the right hallux will be the involved toe. In a fundamentally sound right-handed golf swing, the right foot will be propelled onto the tip of the hallux at the end of the follow through. This can cause a jamming of the toe into the top of the shoebox. With repetition, the subungual tissue will be injured and blood will form under the nail plate. This can cause pain due to the pressure the blood exerts on the nail bed.
Patient symptoms include pain in the hallux, pain with pressure on the hallux toenail and a discolored hallux toenail. The examination reveals pain with palpation of the hallux nail and usually a dark discoloration beneath the hallux nail.
Treatment options of this condition commonly involve: drainage of the blood under the nail; accommodative padding to decrease the pressure on the nail bed; and possibly avulsion or permanent removal of the nail plate.
Adjustment in the golf swing to prevent the irritation of the nail is necessary to eliminate recurrence. Slightly abducting the back foot away from the target will decrease the pressure applied to the end of the toe in the follow through and allow more pressure on the medial aspect of the forefoot instead of the hallux.
While I did not discuss the use of radiographs with the aforementioned common injuries, they may be necessary to rule out other osseous problems that may be present and causing similar symptoms. Communication with the patient as to the cause of the overuse injuries is critical in eliminating their recurrence.
Frequently, the patient will need to discuss the physician’s recommendations with his or her golf professional to work out the proper changes in the golf swing mechanics. This team approach will allow the patient to continue to enjoy playing golf with a decreased risk of further injury to his or her feet.
Dr. Ward is a member of the Board of Trustees for the American Podiatric Medical Association. He is a Fellow of the American Society of Podiatric Surgeons, the American College of Foot and Ankle Orthopedics and Medicine, the American Society of Podiatric Dermatology, and the American Academy of Podiatric Practice Management. Dr. Ward is in a multispecialty practice in Florence, S.C.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.
1. Campbell JD. Golf injuries. American Orthopedic Society for Sports Medicine, www.sportsmed.org , 2006.
2. Foster L. Dr. Divot’s Guide to Golf Injuries. Dr. Divot Publishing, Inc. North Salem, NY. 2004.
3. Herring K, Pearson K. A guide to preventing and managing golf injuries. Podiatry Today 2004;17(4):26-36.
4. Daniels M. Golfing foot injuries. www.wetreatfeet.com , 2009.
5. Stude DE, Gullickson J. The effects of orthotic intervention and 9 holes of simulated golf on gait in experienced golfers. J Manipulative Physiol. Ther. 2001:24(4):279-87.