Physiotherapy and Golf Injuries – Part 1 – The Wrist
In the first of a series of articles on injuries common in golfers of all abilities, ETPI.com’s Nigel Tilley – a Consultant Physiotherapist on The European Tour – examines potential wrist problems and recovery routes.
Golf is a sport with many health and well-being benefits. It is played across the world by people of all ages including into their 80’s and 90’s with a reported 60 million participants. The health benefits have been widely reported in recent years with an 18-hole round representing somewhere between six to eight kilometres of walking and often requiring physical exertion across variable outdoor terrain. This can burn more than 1,500 calories as well as requiring more than 8,000-12,000 steps.
A recent Scandinavian study of more than 300,000 golfers showed that people who play golf on a regular basis have a 40 per cent decreased mortality rate compared to their peers, which equates to a five year increase in life expectancy – regardless of gender or socio-economic status.
Another study found that walking 18 holes of golf was the equivalent of moderate-high intensity exercise for the elderly and moderate for the middle-aged.
But it isn’t just physical benefits to be gained from playing golf. The sport suits participants of all ages, abilities, sex and age, who can all play together providing unparalleled socialisation opportunities and psychosocial benefit.
Golf is much more than just walking and can be very demanding, requiring strength, endurance, explosive power, flexibility and athletic ability to perform a movement which produces some of the fastest club head and ball speeds of any sport.
However, the effect of repeated large forces on the body can lead to a number of different types of injuries. Due to the biomechanical requirements of such an asymmetrical swing, these are often specific to certain areas and sides of the body in golfers depending on their lead side. For instance, right handed golfers, wholead with the left side, are more likely to suffer from Extensor Carpi Ulnaris (ECU) injuries on the left wrist and Dorsal Rim Impaction Syndrome DRIS injuries on the right wrist.
A wealth of research has been conducted on the types and likelihood of injuries experienced by golfers with the back, shoulder, elbow, wrist and hips appearing the main areas of the body prone to problems.
These injuries are generally caused by acute trauma, poor technique, a lack of physical conditioning, the accumulated effect of repetitive movements over many years or a combination of these factors while, interestingly, the occurrence of certain pathologies differ between amateur and professional golfers.
Now, in the first part of our series on golf injuries and physiotherapy, we look at the wrist, potential injuries to the joint and associated soft tissue, and how physiotherapy can help in the treatment and rehabilitation of an injury in order to fast-track recovery and help return you to activity as effectively and efficiently as possible.
There are a large range of common wrist injuries in golf but in this brief study we will concentrate on one commonly seen in a variety of golfers. – the Extensor Carpi Ulnaris (ECU) injury.
What is it?
The ECU is a skeletal muscle located on the ulnar side of the forearm which acts to extend and adduct the wrist. It has to work very hard during the golf swing and so is highly prone to injury in golfers. ECU pathologies include tenosynovitis of the tendon sheath, tendinopathy, tendon disruption and tendon instability. These injuries can occur in isolation or combined and can be caused by high force trauma, such as hitting a tree root or thick grass, rapid increase in loading, continued excessive loading and technique faults. This can lead to a variety of changes at the tissues depending on the stage, severity or structure affected including cellular tissue disruption, thickening, matrix breakdown and increased vascularity.
How does physiotherapy treat this type of injury?
The key aim of physiotherapy is to attempt to clearly identify the injury and its cause. This greatly helps direct the golfer’s treatment and management. Often this type of injury will require ‘load modification’ with more traumatic sudden onset injuries requiring immediate removal of load and PRICE protocol (protection, rest, ice, compression and elevation) or POLICE (protection, OPTIMAL LOADING, ice, compression, elevation). The aim here is to reduce the bleeding and swelling from the injury site if severe tissue disruption such as a partial or full rupture has occurred.
In presentations that have a more gradual non-traumatic onset, a reduction rather than removal of load is often required. This reduction in load can be achieved by encouraging the hitting of less balls or avoiding hitting from hard ground or mats – which often increase the stress on these tissues. There are several strapping techniques which physiotherapists use that can also help to stabilise the wrist and give support to the structures.
In layman’s terms if your problem is a slow gradual onset of pain and symptoms in the outside of the wrist a reduction in the amount of balls that you hit or stopping practicing on hard winter matts may help to reduce symptoms and allow recovery In situations where a sharp and sudden onset occurs after a specific incident (like hitting a tree root or when hitting out of heavy rough) you may need to stop playing golf immediately for a period of time and see a physiotherapist of wrist specialist for a detailed assessment of your injury.
The rehabilitation of injuries to the ECU and its associated structures depends on the exact injury and the severity of the tendinopathy. But where no severe tissue disruption has occurred – as opposed to partial and full ruptures, which could require surgical opinions or interventions- the aim is to gradually restore the tissues ability to tolerate load through load management, isometric and eccentric exercises and graduated return to play. As with so many injuries in golf it is key that technique and playing habits are reviewed to help identify solutions to poor technique and practice faults which can often lead to excessive stresses on certain parts of the body. For example, reduced ability to separate your pelvis from your upper body during the back swing is often associated with a higher incidence of wrist, elbow and shoulder injuries, due to the poor swing techniques these limitations create.
A golf-specific physio such as those that work at the ETPI in Terre Blanche and Jumeirah Golf Estates will be able to help you with these sort of biomechanical adjustments or conduct a joint assessment with a golf coach or instructor.
For safety, optimum treatment and to reduce the risk of re-injury, players and patients should visit and complete a full assessment of all injuries and receive treatment and rehabilitation under the guidance of a chartered physiotherapist.
Part 2 of this series on ‘Physiotherapy and Golf Injuries’ will look at ‘The shoulder’ and will be out next week.
To see an in depth guide for sports physicians and physiotherapists on examining the wrist and assessing its injuries you can watch this video by European Tour Chief Medical Officer Dr Roger Hawkes and Consultant Wrist & Hand surgeon Mr Doug Campbell:
The European Tour Performance Institutes in Terre Blanche, France and at the Jumeirah Golf Estates in Dubai have highly qualified and expert physiotherapists, osteopaths, medical staff, biomechanists and support staff that are able to help you with your injury assessment, diagnosis, treatment and improve your golf performance. To arrange a visit or book an appointment with them email:
Glossary of Terms
Isometric – is a type of strength training (muscle action) in which the joint angle or muscle length do not change during the muscle contraction.
Eccentric – Is active contraction of a muscle occurring simultaneously with lengthening of the muscle. The muscle elongates while undertension due to an oppossing force greater than the muscle generates.
Concentric – A concentric muscle action is a type of muscle contraction where the muscle is shortening while generating force. This occurs when the force generate dby the muscle exceeds the load opposing its contraction.