Rehabilitation and care of the golfer around low back pain

Among the most stubborn misconceptions about golf, there is one that is maintained even by some health professionals, namely that the practice of golf leads to the appearance of low back pain.

The golf swing is a highly integrated sport that requires three-dimensional mobility and strength especially in the hips and pelvis. There are approximately 23 ranges of motion in the body that are essential for an effective swing, and none is more important than the femoroacetabular joint (also known as the hip joint). Rotating the pelvis during the golf swing is one of the key movements, promoting stability and power transfer during both phases of the swing.

When acetabular-femoral joint rotation is limited in one or both joints, rotational demands are transferred proximally to the lumbar region, spine, and sacroiliac joints. This compensation affects the biomechanics of the swing and leads to mechanical breakdown in the swing region. lumbar spine.

We will therefore discuss the effects of low back pain on golfers and then see the biomechanics of the swing and the constraints imposed on this area.

We will see that some restrictions may cause the risk factors, but there are ways to avoid them.

Incidence of low back pain in golfers 

It is the most frequent pathology in golf since approximately 50% of amateur golfers and 30% of professional players have already felt pain in this area.

Lumbago corresponds to the pain felt by the golfer at the level of the Lumbar spine (bottom of the spine).

Golf is not necessarily the cause of these pains but can reveal existing problems. To date, epidemiological data invalidate the notion of golf-related excess risk.

Low back pain is the leading cause of career interruption among professional golfers. (Smith & all, Sports Health 2018)

This low back pain is governed by 3 predominant factors:

– The biomechanics of the golf swing: the spine and vertebrae.
– Posture and the golf swing
- Equipment.

We will therefore see how to anticipate and take care of this low back pain.

But first, let's look at the biomechanics of movement at the lumbar level to understand the constraints imposed there.

The stresses borne by the spine 

• In daily life: 1 to 4 times body weight for moderate physical activity at the L4-L5 and L5-S1 level (last 2 levels of the spine)
• When playing golf: 6 to 8 times the body weight on the last lumbar disc at mid-downswing.

The main factor causing pain in the lumbar spine is the lack of mobility.

Research has shown a positive correlation between decreased dominant hip rotation and lumbar range of motion with a history of low back pain in professional golfers. Study carried out in 2004 by Dr James Andrews et all.

The author's hypothesis was that the capsular pain occurred due to hypertonicity of the external hip rotator and inhibition of the corresponding internal rotators.

There is in the literature, particularly among golfers, a correlation between low back pain and mobility restrictions.

Mobility restrictions (Scientific evidence)

• Significant correlation between limitation of hip internal rotation and low back pain in high-level golfers.
• Comparative examination of hip rotations is essential for golfers with or without low back pain +++.
• Increased right side bending of the lumbar spine at impact and during follow through.
• Decreased pelvic rotation during follow through and finish.
• Increased axial rotation of the lumbar spine at top backswing and finish.
• Increased lumbar kyphosis on impact.

All this increases lumbar stress during the swing: Posterior intervertebral and articular discs.

In addition to mobility restrictions, from a technical point of view there are also golf-specific risk factors.

Golf-Specific Risk Factors 

• Posture (position at address). = Neutral: better mechanically / C: prestresses on the intervertebral disc / S: prestresses on the posterior joints.

• Mobility restrictions:
  • Internal rotation of the right hip in the right-handed person (Backswing),
  • Internal rotation of the left hip in the right-handed person (Downswing)

• Muscle recruitment abnormalities.
  • Contraction delay: players with low back pain versus asymptomatic players:
    • Grand oblique: backswing.
    • Small oblique: downswing.
    • Decrease in strength and endurance on the multifidius in low back pain players.
  • Decreased endurance on the transverse abdomen in low back pain players.
  • Importance of cladding work in dynamics!! (Lindsay et al., Asian Journal of Sports Medicine 2014 Dec)
  • Impact on balance and coordination

• The dissociation ante / retro version.
  • Must be tested at high speed!!! clinically and not slowly.
  • Must be tested in a standing position, "Address" type +++.
  • Educational and preventive axis in young players!!
  • Axis of prevention of recurrences in low back pain players.
  • Axis of work in physical preparation to improve performance.

• The shoulder/pelvis dissociation.
  • It is essential for a successful swing.
  • It is systematically tested among high-level players (and hopefuls): it is worked on with a view to performance and prevention.
  • 2 aspects:
  • Fixed shoulders over pelvis.
  • Pelvis on fixed shoulders.
  • And among the amateur practitioner? Interest of the compact swing?
    • It's The X Factor: It's the difference between shoulder rotation and pelvic rotation at the top backswing.
  • Various studies have shown that there is no correlation between the X factor and clubhead speed at impact. (Cheetham et al. 2001)
  • But the modern swing requires a large X-Factor at the top backswing and a large "stretched" X-Factor at the beginning of the downswing. (Kwon et al. 2013)

• The "Crunch" factor: This is a characteristic of the swings of high level players:
  • At impact and during follow through.
  • At the same time combination of a lateral inclination of the lumbar spine and a high speed of rotation of the pelvis. (Cole & Grimshaw, 2014)

• Technical issues:
  • The finish in hyper extension / The slide / The inverted pivot.
  • Hardware fault

Nevertheless, there are simple methods to reduce risk factors for low back pain in golfers.

Exercises to suggest to your golfers to reduce the risk of low back pain

– Ante and retroversion of the pelvis on the ground on the back then on all fours 

– Knight serving: Arm up to the shoulders, turn then push with outstretched arms. (Half Kneeling Position)

– Standing: ante and retroversion of the pelvis with assistance

– Sitting: Picking up objects from the floor on the sides: stimulation of the anterior and posterior canals of the inner ear. (Responsible for stabilizing the spine)

– Tie your shoelaces on 1 foot: stimulation of the anterior and posterior canals of the inner ear as a priority + horizontal canals, utricles and saccules.

– Sitting to standing with pivot on the side: stimulation of the anterior and posterior canals of the inner ear as a priority + horizontal canals with each rotary movement.

– Standing Lunge position: row with one arm

– Work on the quadriceps: the incidence of low back pain in professional golfers is inversely proportional to the strength of the quadriceps.

– Work of the transverse and obliques

Golf: an activity for the prevention of physiological aging of the spine 

On the other hand, the practice of golf is very interesting in the context of the prevention of physiological aging of the spine:

• Preserve (as part of ageing) or improve muscle strength (abdominals, gluteus maximus, posterior muscles of the lumbar region, etc.);
• Maintain or improve the extensibility of tendons and muscles;
• Preserve or improve the qualities of proprioception (sense of balance + sense of position in space);
• Preserve or improve dissociation capacities:
  • Shoulders in relation to the pelvis (and vice versa),
  • Anteversion and retroversion of the pelvis (constitute a basic element of the rehabilitation of low back pain for several decades!).

Finally, the constraints measured at the lumbar level during the golf swing are important to know:

• They are maximum between 70% of the downswing and impact 5;
• They correspond to 6 times the body weight in amateurs and 7 times in professionals 6, 7, this at the level of the L5-S1 intervertebral disc.

Good advice

• Do a 7 to 10 minute warm-up without the golf clubs before hitting your first balls. You will reduce the risk of injury and you will play better!
• Adopt a swing adapted to your age, your morphology. Check it out with your pro teacher who is your swing doctor.
• Play both sides to improve muscle strength symmetry.
• No excessive play (overuse)
• Carry out a fitting to be certain that your equipment is perfectly adapted to your level of play, your age, your morphology… This is where the club doctor comes in!
• Pay attention to the frequency of shots at the driving range: maximum 3 balls per minute! This greatly reduces the risk of injury.
• Beware of excess practice after a winter break, for example! It is necessary to resume the practice gradually.
• Be careful when driving on mats resting on a hard surface (concrete)! Prefer practice on grass, but this is not easy in many clubs in France!

To conclude

• The practice of golf is not responsible for the various lumbar pathologies, it only reveals a pre-existing state linked to the classic aging of the spine.
• The practice of golf has a positive impact on the aging of the osteo-articular system and in particular the lumbar spine.
• "I have lower back pain so I can't play golf" is a received idea to fight, but we must accompany the practice of our sport with simple precautions (see good advice).
• The Benefits/Risks analysis of playing golf is positive even in low back pain individuals in the majority of cases.