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Essential Keys To Diagnosing And Treating Lower Extremity Golf Injuries

Having a grasp of proper golf biomechanics is crucial to addressing and preventing injury in the foot and ankle. In addition to reviewing the unique phases of the golf swing and factors that affect stability and balance, this author offers insights on the biomechanics of golfing, and how lower extremity pathology can affect one’s play.

Golf injuries of the upper extremities, back and neck are well documented in the literature.1 Injury to the lower back is the most common injury and frequently results from an incorrect swing by amateur golfers with over-rotation as one of the leading causes.1 In contrast, golf injuries in the lower extremities are poorly represented in both scientific studies and theory.1,2 Acute injuries in the foot appear to comprise around 2 percent of the total reported golf injuries.3

Despite this lack of literature, the feet play an important role in achieving a low handicap status. While many articles on golf and the lower extremity relate to the hip and knee, most golf instructors will tell you that the power of a swing is created “from the ground up” beginning with the feet. In golf, each foot has its own role unlike that of progressive forward gait. The podiatric requirements of the golfer’s lead foot (foot closest to the target or the left foot in a right-handed player) differ significantly from that of the trail foot (foot furthest from the target or the right foot in a right-handed player).  

Most golf injuries to the feet and ankles are either overuse injuries, due to therepetitive nature of swinging the golf club in the same or similar form with each swing, or injuries that are common for any weightbearing activity with these injuries including blisters, stress fract ures, neuromas, ankle ligament strain, plantar fasciitis and tendinitis or tears.

Blistering was the most common lower extremity injury in one of the earlier articles on golf-related foot injuries of the foot.3 Lateral injuries of the foot and ankle would be common due to walking and playing on uneven surfaces, and excessive rolling in the follow-through.3 Authors have cited the development of a third interspace neuroma in the lead foot as the most common golf-related complaint in one podiatric practice while other common overuse injuries include extensor tendonitis from repetitive use of the golf cart brake.4 The most common literature relative to golfing foot and ankle injuries or pathology focuses on shoewear or more recently orthotics.5 There is very little literature relating to foot type, foot pathology or post-op status.

Golf is a sport of complicated and complex actions that requires coordination of timing, muscle function, range of motion demands and movement along unfamiliar planes of axes. Simply addressing injuries is no longer sufficient when discussing the podiatric implications of golf. Over the past two decades, biomechanics of the golf swing have exploded. There are now PhDs who practice solely in the field of golf science. Physics, engineering and biomechanics have grown exponentially in areas of golf such as club design, ball performance and golf instruction.

While the upper extremities dominate the literature on golf biomechanics, little is written on the biomechanical consequences of foot deformities or pathology on the golf swing, although it is a widely held belief that power and speed derive at least partially from the lower part of the body.  

A Quick Primer On The Different Phases Of The Golf Swing

Gait and foot function during golf are unlike in any other sport. Except when one is walking to the ball, the podiatric requirements are not like activities with forward gait as in walking and running, or the spontaneous active motions with basketball or other court sports. Instead, foot function during the golf swing involves variability in foot position and stance, passive movements in addition to active movements, regular consistent movement and weight shift of each foot independently, and the transfer of weight between the two feet.  

Golf is divided into several phases: the address or setup, which is static; the backswing, which places the club in position for the productive portion of the swing; the downswing, which pulls the club head to the ball for ball contact; and finally, follow-through, which is from the point of impact to the static finish. The backswing transfers weight from the front foot to the back foot, increasing the lateral force on the back foot. The reverse happens in the downswing and follow-through but much more rapidly. The finish involves completing the rotation and transfer of weight to a point beyond the front leg. The swing is far from natural and technical errors or faults can occur at any point of the golf swing.

Amateur golfers often seek instruction to correct shortcomings of their swing. Many of the swing faults realized at impact are due to compensations from a problem earlier in the swing sequence including address position, stance and balance. While most golf instructors are acutely aware of anatomical positioning of the feet, they are not familiar with anatomical limitations. Foot type, joint pathology and tendon injury or weakness would all seemingly have an impact on the golf swing at the various stages of the swing.  

The setup is the only aspect of the swing that a golfer can consciously control. Unlike the grip, angles of the spine and knee flexion, foot position during setup has some variability.6 Golfers generally get advice to have their feet shoulder-width apart for a stable stance, balance and central center of mass (center of gravity), and slightly flared out (i.e. abducted) at the address phase.

Pertinent Factors That Impact Stability And Balance On The Course

Stability is an important factor in performance in both accuracy and distance, and is also a contributor to the amount of power generated.1 The lower body needs to be the stable foundation for the upper body during the rotation required for the backswing and the trail foot is expected to remain relatively stable during this rotation. It is widely held that if the stance is too wide, rotation would likely be reduced, thereby lessening maximum power. If the stance is too narrow, stability would be compromised. What has yet to be studied is the variability of stability of the trail foot with foot type. A pronated foot type might limit the stability needed in this capacity.  

Balance is relative to our center of mass. In golf, balance depends on many factors other than foot position, including those factors we have no control of such as a hilly lie or less than desirable surfaces such as sand, high grass or wet grounds. Foot position is one aspect we can control. Balance is crucial to controlling the club during the entire swing and is characterized by weight distribution of the feet both side to side as well as from the rearfoot to the forefoot.

Differences in opinion exist as to which foot to put more weight on and is often based on club selection and the desired placement of center of mass. Some feel golfers should place more weight on the trail foot to provide a stable point to pivot around. Hume and colleagues advocate that 50 to 60 percent of the golfer’s weight should be on the back foot while others stress the importance of having 60 percent weight on the front foot to ensure the low point of the swing is in front of the ball.9

One podiatric study involved using the center of mass as a tool for assessing balance while most of the evaluation tools in the golf world evaluate center of pressure.7 The center of pressure represents the vertical component of ground reactive forces. David Wright, PhD, PGA, of Wright Balance Technology, has found that the club path line is always determined by a line drawn between the center of pressure of each foot.10 I have not found any literature that addresses the impact of foot or ankle pathology such as tendinopathy of the posterior tibial tendon on the ability to bear greater than 50 percent of one’s weight on either foot during the static phase of golf at the address phase. Interestingly, authors have studied knee position relative to center of mass and balance, finding flexion of the knees at the address phase to lower the center of mass and increase balance.11

The importance of proper foot setup goes beyond the width of stance at setup. There is considerable thought on where golfers should place their weight from the rearfoot to the forefoot. Many golf professionals and instructors promote staying on top of the ball by putting the center of mass forward or at the ball of the feet. Tears of the plantar plate would surely be a factor with this stance position. Since club head velocity is associated with weight transfer to the lateral lead forefoot in amateur golfers, footwear or orthoses that shift weight anteriorly and laterally could help increase club head speed in this group.12 Podiatrists can facilitate this weight shift by writing orthotic prescriptions that elevate the heel and provide medial arch support.

However, many golf pros feel the weight needs to be on the midfoot and there are even OTC golf training inserts that push people onto their midfoot or rearfoot by elevating the digits. If the center of mass is too forward, not only does it put balance at risk but it changes the swing plane on the backswing. This could in turn interfere with the transfer of weight to the trail foot or change the axis of the swing plane during the backswing, both of which could affect the swing plane on the downswing, and result in coming “over the top” as compensation producing a slice. Given the consequences that can occur with a setup that has too much pressure distally on the front foot, it is easy to imagine that these same problems could occur with someone who has ankle joint equinus or plantar fasciitis, both of which would prohibit maintaining heel pressure.  

Whether or not to “flare out” the toes is another area of contention. Standing with your feet straight or pointed out a few degrees is most golfers’ normal stance. By abducting the trail foot further, it allows for the hip to reach a greater rotated position in the backswing, therefore providing more power on the downswing. Abducting the lead foot provides more room to roll over during the follow-through.

However, abducting either foot and externally rotating the tibia places that foot in a more pronated position, which would limit the amount of pronation available for the swing. This pronated position could also force the center of mass too far medial for proper balance. The stability of the golfer may also be sacrificed.

If a golfer has limitations in hip rotation or knee pathology, abduction of 10 to 20 degrees is certainly a recommended option, but it is doubtful that an instructor would take a golfer’s angle of gait or transverse plane deformity into consideration. Someone with significant metatarsus adduction would not be able to “flare out” and have a stable and full range of motion required for a smooth swing.

Biomechanical Considerations With The Golf Swing

The ultimate goal of the golf swing is to maximize both distance and acceleration. The lower body needs to be the foundation for the upper body during the rotation required for the backswing. Success of the swing depends on the lower extremities’ ability to function efficiently as well as the upper extremities. A recent study has shown that club head velocity was directly related to the total work force of the joint kinetics of the lower extremities and suggested that the lead leg may be specifically relevant.8 Researchers have shown that the use of custom orthotics on a continual basis increases club head velocity.13

Maximizing speed and distance comes from all aspects of the swing, but there is little research on the foot’s influence on swing. That said, foot position, motion and weight distribution greatly affect weight transfer, the body’s ability to rotate and ground reaction forces, all of which create speed, energy and efficiency.  

The backswing, or takeaway, is intended to give the golfer the best possible position for the most powerful downswing and to maximize the power of the muscles involved. There is debate on whether golfers best accomplish this by simply transferring body weight or by rotation. Those who advocate a lateral shift of weight transfer feel that rotation may decrease the speed of the swing by involving an additional plane of motion. Most instructors prefer rotation as it provides a windup for power using the gluteal muscles and the posterior muscles of the legs while maintaining the body’s center of mass within the base of support. Muscle dysfunction of the gastrocnemius and/or soleus could certainly impact the power needed for the downswing with rotation.  

Foot motion occurs in all three planes of motion and foot position depends on rotation of the hip, femur and tibia, resulting in passive motion. Transitioning weight from anterior to posterior and vice versa also occurs during the golf swing. Weight shifts medially as well as posteriorly off the forefoot on the lead foot and onto the trail foot slightly from posterior to anterior during the backswing. On the downswing to follow-through to the finish, the trail foot forces return to the heel and go from rearfoot to forefoot with plantarflexion, finishing with increased stress to the first metatarsophalangeal joint (MPJ) and extending to the hallux.14 One must consider the peroneus longus tendon function on the back leg during this part of the swing as it plantarflexes the first ray.

Foot stability becomes an important factor in both the takeaway (requiring a stable trail foot) and in the follow-through (requiring a stable lead foot) as does the ability to both pronate and supinate sufficiently. Assuming a rotational swing, the front or lead foot becomes pronated in the backswing and supinated in the downswing. The trail or back foot would naturally become slightly supinated with hip rotation in the backswing and pronated in the downswing and follow-through.  

Golf instructors frequently manipulate players’ foot action to accomplish specific goals. Kelvin Miyahira, who has been teaching golf for nearly 30 years, is a strong advocate for allowing the trail foot to supinate in the backswing prior to the pronation that occurs with the downswing while newer teaching methods from the golf instructor David Leadbetter have golfers actively pronating the trail foot on the backswing.15 Others advocate keeping weight medially on the trail foot through the backswing by keeping the foot straight at setup and pronating slightly.  

Miyahira is also adamant that the heel be allowed to naturally come off the ground in the backswing on the lead foot.15 He and others who advocate natural offloading of the heel emphasize that full rotation of both the upper body and the lower body cannot occur with the heel planted. The lead leg (left leg in a right-handed player) internally rotates following hip rotation and the foot naturally pronates and plantarflexes as the body elongates to maximize club distance at the end of the backswing. Forcing the heel to stay on the ground will not only limit rotation but may strain the medial structures.  

Similar controversies exist on the follow-through to finish. Miyahira insists the heels be allowed to offload as lifting the heels will facilitate hip rotation in both directions of the swing.15 Certainly, someone with a tight posterior muscle group, decreased hip extension or decreased internal tibial rotation will need to allow the heel to come off the ground. From a podiatric perspective, forcing people to remain on their heels when they are physically unable to would put undue pressure on the gastrocsoleus complex and may result in Achilles tendonitis, tendon or muscle tears, or even posterior calcaneal spurring.   

Miyahira also expresses concern that newer golf instructors are teaching players to keep their lead foot planted on the ground during follow-through to the finish as opposed to allowing supination to occur.15 His concern is that rotation is limited. However, by not allowing the foot to supinate, the tibia externally rotates around a fixed foot, causing strain to be placed on the knee, the fifth ray and the lateral structures including the peroneal tendons, which could be at risk for injury.  

Taking Foot Pathology Into Account With Golfers

While the golf world attempts to dictate foot position to increase both stability and motion, there has been no consideration of foot type or pathology. A golfer’s ability to achieve a supinated and more stable position may be hindered by a pes planus foot or a foot with a partial rupture of the posterior tibial tendon. A golfer with a cavus foot may never be able to transfer weight medially to achieve the desired weight shift. The Achilles tendon and posterior tibial muscles and tendons will surely have an effect on one’s ability to plantarflex when necessary.

The peroneal muscles are important muscles used in golf for stability during the swing and patients frequently present with peroneal tendon pathology in most podiatric practices.16 The rapid pronatory motion of the trail foot in the downswing to finish may cause concern for the peroneal tendons including avulsion of the peroneus brevis.

The ability of the first ray to plantarflex, the ability to load the hallux and the availability of first metatarsophalangeal joint (MPJ) motion are certainly factors that could affect the golf swing. The sesamoids and plantar plates are all susceptible to repetitive trauma during golf with some players. There is no mention of sinus tarsi syndrome in the lists of injuries related to golf. A golfer with an inflamed or chronically adherent sinus tarsi would certainly be at risk for continued injury with the repetitive motion of the subtalar joint. A golfer with chronic lateral ankle instability would undoubtedly suffer ankle sprains if left unsupported.

In Conclusion

With the field of golf science developing more and more each year, it is my hope that some of this research will focus on lower extremity deformities and pathologies, and the limitations and challenges that they may present to the golf swing.

Dr. Reid is in private practice at Family Podiatry Center in Naperville, Ill. She is a Past President of both the Illinois Podiatric Medical Association and the American Association for Women Podiatrists.

The author thanks Chicago golf instructor Lloyd Higley for his availability and tireless hours of instruction, explanation and assistance in the thought process of relating golf biomechanics to podiatric issues over the past few years.

References

1.    McHardy A, Pollard H, Luo K. Golf injuries: a review of the literature. Sports Med. 2006; 36(2):171-87.
2.    Meister D, Ladd AL, Butler EE, et al. Rotational biomechanics of the elite golf swing: benchmarks for amateurs. J Appl Biomech. 2011; 27(3):242-51.
3.    Pietrocarlo TA. Foot and ankle considerations in golf. Clin Sports Med. 1996;15(1):129-146.
4.    Ward P. A guide to common foot and ankle golf injuries. Podiatry Today. 2010; 23(8):74-77.
5.    Pande P. Golf swing biomechanics: Footwear considerations. Lower Extremity Review. June 2016.
6.    Maddalozzo G. An anatomical and biomechanical analysis of the full golf swing. Nat Strength Conditioning Assoc J. 1987; 9(4):6-9.
7.    Najafi B, Wrobel J, Lee-Eng J, Groebel R. Estimation of center of mass trajectory using wearable sensors during golf swing. J Sports Sci Med. 2015; 14(2):354-363.
8.    McNally M, et al. Lower extremity work is associated with club head velocity during the golf swing in experienced golfers. Int J Sports Med. 2014;35(9):785-788.
9.    Hume P, Keogh J, Reid D. The role of biomechanics in maximizing distance and accuracy of golf shots. Sports Med. 2005; 35(5):429-449.
10.    Personal communication, David Wright.
11.    Bechler J, Jobe FW, Pink M, et al. Electromyographic analysis of the hip and knee during the golf swing. Clin J Sort Med. 1995; 5(3):162-166.
12.    Pataky T. Correlation between maximum in-shoe plantar pressures and clubhead speed in amateur golfers. J Sports Sci. 2015; 33(2):192-197.
13.    Stud D, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on club-head velocity in experienced golfers. J Manipulative Physiol Therapeutics. 2000; 23(3):168–174.
14.    Cavanaugh P, Williams K. The mechanics of foot action during the golf swing and implications for shoe design. Med Sci Sports Exerc. 1983; 15(3):247-255.
15.    Personal communication with Kelvin Miyahira.
16.    McMaste R. How to use your golf muscles. Australian Golf Digest. December 2006.
17.    Worsfold P, Smith N, Dyson R. Low handicap golfers generate more torque at the shoe-natural grass interface when using a driver. J Sports Sci Med. 2008; 7(3):408-414.
18.    McCarroll JR. The frequency of golf injuries. Clin Sports Med. 1996; 15(1):1-7.
19.    Thériault G, Lachance P. Golf injuries. An overview. Sports Med. 1998; 26(1):43-57.

For further reading, see “A Guide To Common Foot And Ankle Golf Injuries” in the August 2010 issue of Podiatry Today or “A Guide To Preventing And Managing Golf Injuries” in the April 2004 issue. 

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Marlene Reid, DPM
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