Golf is a sport practiced all over the world which is rapidly gaining more and more popularity. The proof of its popularity and the success of Golf is its return to the 2016 Olympics after 112 years, held in Rio de Janeiro.
Recently, following the increased interest, numerous scientific studies have been carried out aiming to identify the key factors influencing golfing performance and the main risk factors of injury.
In this regard, golf is considered a low-impact sport and many golfers practice this discipline as a form of exercise at a recreational level.
The social environment also carries a great importance amongst participants practice at this level. Golf is very popular for more older generations, and it is often recommended as a means to increase activity levels, and to help recover following a total knee arthroplasty (TKA) (McGrory et al., 1995).
However, the incidence of knee injury in golf is comparable to that of high-performance impact sports such as basketball (Borowski et al., 2008). In fact, the situations in which elevated loads occur on the joints, directly relates to the lower limbs. However, chronic and acute injuries are frequently reported in golf, involving in particular the lower back and the knee (Gosheger et al., 2003).
From the literature, a general consensus seems to be emerging regarding the likely association between accidents in the golf and poor or inconsistent techniques repeated over time. Most scientific studies on golf injuries have dealt with those related to the knee.
The main injuries for golfers
Osteochondral fractures of the patella, tibial stress fractures, medial meniscus tears are among the most frequent injuries in this discipline.
Studies have shown that older amateur players are at greater risk of knee injuries compared with younger players (Fradkin et al., 2005). The idea that players may be subject to trauma as a result of the aggravation of previous pathological conditions is consistent with the results of multiple studies. In fact, Gosheger et al. (2003) reported that 31.3% of the players who experienced chronic knee pain before golfing, reported that the practice made the symptoms worse.
The effects of golf on young golfers
Since most of the studies carried out so far have focused on adult golfers, the effects of the game and its practice at a young age have not yet been well documented. According to Cabri et al. (2009), younger players are rarely exposed to conditions that promote injuries to the skeletal muscles or joints; however, this is not the only way to prevent these injuries.
However this statement may not be as true as it once was, given the higher intensity proposed the new training programmes. As a result, some of these younger golfers, particularly elite athletes, may be subject to excessive load conditions. Apart from age, a clear consensus was not reached among studies aimed at identifying groups particularly subject to the risk of knee injury. In addition, surveys on both male groups and women have not reported consistent evidence on the potential risk of injury, regardless of the level of play (McCarroll and Gioe, 1982).
Short review of golf literature
Injuries independent of knee condition data in the literature suggest that this type of injury may be caused by different mechanisms; however, these may be influenced by their background and by the level of participation. Several studies have submitted to the participants surveys on the following topics mechanisms and age at which their knee injuries occurred.
Golfers examined by Batt (1992) attributed their injury to incorrect knee swinging, to a technique of wrong shot or irregular support on the ground. Other authors reported that 95.7% of the players felt that their knee injury was due to excessive practice. Additionally further studies have shown that the impact with the ball (30.4%), the follow-through (38.5%) and the swing phases were the most common points in which injuries occurred.
In line with these results, McCarroll and Gioe (1982) reported that 68.7% of golfers' injuries professionals was due to repeated practice of swinging.
Patterns of movement
In this regard, during this movement, some patterns of movement can be identified:
- Rapid extension of the knee that occurs at a flexed joint between 0° and 30°
- Remarkable internal tibial rotation
- At low flexion angles, the activity of the posterior muscles of the thigh is ineffective in the actively curbing anterior tibial displacement and thus contributes primarily to increased joint compression
- strong quadriceps activity contributing to a high joint load
In several surveys, the average age of injured golfers was very high, with a survey revealing that players between the ages of 60 and 65 were at the top of the list risk of injury to the lower limbs compared to other younger practitioners (Baker et al., 2017).
Interestingly, in an informal, non-peer-reviewed survey conducted by a former champions of the Professional Golfers 'Association (PGA) was found that 55% of the players interviewed in a PGA Champions had suffered a knee injury at the advanced point of the their career, perhaps indicating an association between long-term participation and trauma. In addition, 83% of injuries were to the left knee and only 17% to the right knee (Twitty, 2009).
Unfortunately, information on the dominant limb has not been reported in this survey and in general it could be assumed that the sample examined was right-handed and that these lesions were are then verified in the opposite (left) knee. Finally, the effects of fatigue should also be considered when attempting to identify risk factors during golfing. Vandervoort et al. (2012) highlighted that walking to cover the game distances provides an opportunity to maintain a certain level of cardiovascular fitness, however, during a game, this can contribute to a better greater tiredness, especially in older players.
Golf and injuries related to arthroplasty
Golf is used as a part of post-operative rehabilitation programs. On the contrary, sport high-impact jogging and tennis is often not recommended or allowed. Surgeons orthopaedists commonly recommend golf as a rehabilitation activity after TKA.
Some studies show that amateur golfers active after TKA, about 15.7%, have mild pain while playing golf, while 34.9% only experience pain after playing. In a studio conducted by Mallon et al. (1996) 3 professionals and 39 amateur golfers with TKA were interviewed after returning to golf. In this analysis, professional players did not report pain or pathological conditions in the next 4 years.
Some studies show that amateur golfers active after TKA, about 15.7%, have mild pain while playing golf, while 34.9% only experience pain after playing. In a studio conducted by Mallon et al. (1996) 3 professionals and 39 amateur golfers with TKA were interviewed after returning to golf. In this analysis, professional players did not report pain or pathological conditions in the next 4 years.
Golf-related knee injuries account for about 15% of all injuries, for the most common injuries as larger players showing a greater predisposition. However, the main mechanisms contributing to knee injuries during golfing are still unknown, or unclear in the literature, but a high joint load and complex movements can undoubtedly increase the risk of injury. Clinics, coaches and players should at the same time to consider carefully participation in or return to golf when there is pain in the knee, following an accident or surgical procedures (including total arthroplasty).
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