A PHYSIO’S GUIDE TO GOLF INJURIES
Last updated: 12.17pm, Thursday 8th April 2021
I often hear and see golfers commenting on swing techniques causing injury. It is a subject that is really interesting and the more I read about it the more complicated it seems to get. Which of the swings above are most likely to cause injury?
They have all been associated with back problems. One thing for certain is that they are all wonderful performers. Also, if you change their swings their injuries may improve but what will this do to their bank balance? We have all tried to change our swing patterns and it doesn’t always result in a better performance- at least initially anyway. Data collected from the European Tour suggests the most common injuries in elite golf tend to involve the spine and wrist. There was found to be no link between injury and age however its possible injured golfers drop out of the European Tour making a conclusion of age not being related to injury misleading.
We currently know the only predictor of a future injury is a previous injury. For example if you have had a back injury in the past you are more likely to sustain a back injury in the future compared to someone with no previous back pain.
We think it may be possible to predict injury however it is still a work in progress. One of the reasons it is so difficult is that injury is likely to be multi-factorial. Injury may be related to one or several factors and their relationship with one another. Below is a diagram from Arsenal Sports Medicine Department of what they feel are factors in predicting injury in football. These factors human in nature and will also affect golfers.
There have been studies demonstrating links between stress, anxiety (psychology), strength, fatigue (internal load), changes in playing volume (external load) and injury. So far there have been no proven links between movement quality and injury. This may be the case as it would be a very difficult relationship to measure. For example how do you measure changes in movement quality? People ideas of quality movement are different also. How many times have you been to two different coaches and they want you to do different things? If you have had an injury golfing or a persisting injury there are lots of things you can do to manage this or at least lower your risk of it returning. The answer lies in the large ovals in the diagram above.
Strength Related
There are many studies suggesting strength training reduces injury risk. This type of training makes body tissues more robust to loading therefore making it more tolerant to swinging a golf club many times over. I feel there is a fear among golfers that strength training itself causes injury. Effective strength training is designed to push muscle tissues to the edge of their capacity which causes an adaptation. If strength training is increased too quickly the risk of injury does go up. My advice to get the most out of your training is to get help from a strength coach.
External Load
External load is the sum of all the training and competition you are doing. For example this would include all practise sessions, practise rounds, competitions and work in the gym. Essentially how much work you are putting in. Football teams use lots of variables to track this data the most obvious being distance travelled and speed of travel which is picked up by GPS vest on their backs (this is the bump you see between their shoulder blades). An easy way to record training load in golf would be in hours.
Studies from other sports have suggested large changes in training load carry an increased risk of injury.
This graph was taken from a study of Australian Rules Football players. Their risk of injury was found to exponentially increase when the amount of weekly training they did increased by more than 50%. For example if you are used to playing 4 hours per week and increase this to 6 hours your injury risk may increase from 3% to 6%. The “sweet spot” is when your injury risk is at its lowest. This sweet spot will be larger for some than others most likely dependant on all their other risk factors for injury.
In short if you are looking to minimise your injury risk or if you are coming back from injury try and avoid fast and large increases in time spent playing/practising. If you know you have a busy playing spell in your season try and build it up in the period leading up to this to allow your body time to adjust. It may also be necessary to practise very little around busy spells of competition. As a compulsive practiser I find this very hard to do!
Psychology/Internal Load
Psychology/Internal Load
There have also been studies in team sports which have found links between injury, sleep and stress.
Try and keep your stress levels down to a minimum and look after your sleep hygiene. Consider simple strategies such as mindfulness, exercise and a healthy diet. It may be worth consulting a Sports Psychologist to find out what may be the most effective for you.
Flexibility
A common belief is that poor flexibility is a cause of injury. There have been lots of factors shown to be linked to injury however flexibility does not appear to be one of them. Flexibility will affect your technique. Flexibility particularly around the hips and upper back is very important in the golf swing. Results from 3D analysis suggest that elite players tend to rotate around 45 degrees through their upper back and 40 degrees with their hips (the pelvis turns as a result of hip movement).
If golfers lack this movement they will compensate by “borrowing” movement from other areas. This is apparent in senior golfers who tend to lose range through the hips/spine. They tend to compensate by elevating their shoulders and lifting their heels and tilt more towards the target rather than turn.
If golfers lack this movement they will compensate by “borrowing” movement from other areas. This is apparent in senior golfers who tend to lose range through the hips/spine. They tend to compensate by elevating their shoulders and lifting their heels and tilt more towards the target rather than turn.
I think it is possible to play well with poor mobility however the top players seem to have good mobility around the hips and spine. If you want to make your swing look like the best players you will have to make sure your flexibility allows you to do this. I don’t feel you particularly need good flexibility to produce lots of club head speed as some long drive competitors don’t appear to have this.
The image below is a comparison of Jack Nicklaus aged 78, Rory McIlroy and Justin James the 2017 long drive champion. Jack and Justin don’t use the same rotation around the hips and spine as Rory. They compensate for this by bringing their left arm up past their chin and lifting their left heel.
Movement Patterns/Technique
There hasn’t been any scientific backing for technique being an injury risk as yet. As mentioned before with all the other factors involved it is hard to work out the influence of technique. I have been lucky enough to spend time in a gait laboratory where we have shifted forces away from painful tissue by adjusting swing technique.
We think this resulted in less pain however the tissue may have settled in time anyway! A good example of this would be in the film below describing Patrick Cantlay’s back issues. Essentially the answer was to get more power from the legs rather than generating lots of force with spine rotation.
From my experience extremes of movement around the hitting zone where forces are greatest tend to be problematic particularly when body tissue has already become painful. For a back an extreme position would be lots of side bend and a wrist position would be away from neutral around the hitting zone.
In the image below Brooks Koepka tends to use lots of ulnar deviation (club down/hands up) and Justin Thomas tends to side bend around the impact position.
Have a think about what you are seeing and reading.
Take care what you read or hear in articles regarding players injuries. There is media hype to be mindful of which on occasion leads to dissemination of poor quality information. A very imformative blog by a well known low back pain researcher Peter O’Sullivan does a great job of highlighting this in the case of Tiger Woods.
The information the player has been given isn’t always helpful or perhaps what the player has taken away from the information being given isn’t correct. A decision to take time out of playing may also be based on multiple factors. For example low back pain with someone in a rich vein of form during a key part of the season might have a different outcome to low back pain with someone towards the end of their career who is struggling with their game. One is probably more likely to take time away from the game than the other with similar levels of pain.
Summary
My advice for managing injury or avoiding injury would be to try and take into account of these factors by:
1. Stay fit and strong to protect your tissue from injury
2. Try and manage your season and avoid large increases and decreases in your playing volume. Mitigate during busy spells with lots of recovery work and try and keep practise volume to a minimum (no compulsive practising!)
3. Good sleep hygiene and effective strategies to keep your stress levels down
4. If you have an injury that is recurrent or doesn’t seem to be settling which is made worse by your golf swing see your local PGA professional about swing errors that may be overloading the painful area. I would also recommend seeing a relevant health professional to get an accurate diagnosis and rule out any serious pathology.
5. Stay flexible around the hips and spine to reduce compensatory movement and help you swing it like your role models.