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Shoulder injuries in golfers
By: Sonia Offord (profile)
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Information on houlder pain, which is a common problem for both amateur and professional golfers.

Fig.1

Have you ever experienced shoulder pain when playing golf? If so, you’re not alone. Shoulder pain is a common problem for both amateur and professional golfers, accounting for 8-12% of all golf injuries1. Interestingly, the lead shoulder, or left shoulder in a right handed golfer, is more frequently injured than the trail shoulder2. Amongst professional golfers, shoulder injuries often result from overuse due to the number of hours spent playing and practicing. In amateur golfers, less than optimal swing mechanics can increase the risk of experiencing a shoulder injury. However, even during a ‘perfect’ swing, the joints and muscles around the shoulder have to tolerate and transmit large forces. If the joints and muscles are not able to tolerate these forces, pain and injury can result. Shoulder pain can be difficult to diagnose and manage. Many golfers decide to ignore the early warning signs and try to play through the pain or change their swing to avoid experiencing the pain. This not only affects your enjoyment of the game, but may result in you developing a chronic shoulder problem that is much more difficult to treat. Early diagnosis and appropriate treatment is the key for managing shoulder injuries and for avoiding significant time away from golf. It is important that you seek advice from a health professional who understands the mechanics of the golf swing, given that examining which phase of the swing symptoms occur can assist in accurately diagnosing the problem. Common injuries that occur during the backswing, downswing and follow-through phases are briefly described below.

Backswing If you experience symptoms on the top of the shoulder at the end of your backswing the pain may be coming from the acromioclavicular joint (ACJ). This is the joint between the end of your collarbone, the clavicle, and the part of your shoulder blade which forms the bony roof of your shoulder joint, called the acromion (Figure 1). The ACJ acts in much the same way as the axle in your car - it functions as a pivot point to allow greater shoulder blade movement which enables you to raise your arm above your head. The collarbone also acts as a strut to absorb the transmission of forces across the shoulder joint. Maximal loading of the ACJ occurs at the top of the backswing when the lead arm is taken high across the body2. In this position the ACJ may be compressed and the golfer may experience a sharp pain over the bony prominence on the top of the shoulder. Exercises that aim to improve the range of movement in this joint, as well as the upper back, may help relieve symptoms (Figure 2).

Fig 2: Stretch to increase ACJ mobility

Shoulder pain at the top of the backswing may also be due to impingement of the rotator cuff tendons and other structures underneath the acromion. The pain is usually felt deeper in the shoulder joint or more towards the outside of the shoulder region. Stretching the soft tissue structures at the back of the shoulder can often help alleviate impingement symptoms by helping to increase the space underneath the acromion (Figure 3).

Fig 3: Rotator cuff stretches

Downswing/Acceleration Pain experienced in the shoulder at the onset of the downswing may be caused by weakness or poor control of the rotator cuff muscles. The most important function of these muscles is to work together to stabilise the shoulder joint, particularly during overhead activities. The shoulder joint actually looks a lot like a golf ball sitting on a tee (Figure 1). Because the ball of the shoulder joint is much larger than the socket, co-ordinated muscular activity is extremely important for holding the golf ball on the tee during shoulder movements that occur throughout the swing. During the downswing, where the aim is to produce optimal clubhead speed, large forces are placed on the shoulders. If weakness exists in the rotator cuff muscles, the ability of these muscles to tolerate the forces and hence control the humeral head position is impaired. This may not only cause strain to the rotator cuff muscles and tendons but to other structures which may be vulnerable to increased loading from poor mechanics. These other structures may include the biceps tendon, shoulder capsule or shoulder cartilage. Strengthening the rotator cuff muscles is one way to help avoid injury (Figure 4).

Fig 4: Rotator cuff strengthening exercises

However it is also very important to ensure adequate flexibility and strength through the trunk so that the forces during this swing phase are distributed evenly3 (Figures 5, 6 - see below).

Follow-through Pain at the end of follow-through may also be indicative of a rotator cuff problem. During follow-through, the rotator cuff muscles are working hard to slow down the momentum of the arm after ball contact and to stop the shoulder from over rotating. If the function of the rotator cuff muscles is impaired, then sprain to the ligaments and soft tissues at the front of the shoulder and/or the ACJ can occur from too much movement of the arm behind the body. This can be avoided by strengthening the rotator cuff muscles and by maintaining a strong trunk and good stance position so that you are less likely to overbalance and compensate by pulling across your body4.

Fig 5: Upper back rotation stretches

TIPS TO AVOID SHOULDER INJURY 1. Check your technique. Have your golf swing assessed by a golf professional to determine what areas you need to work on. 2. Ensure good flexibility and strength of the upper back (thoracic spine). 3. Perform simple rotator cuff strengthening exercises regularly. Use a small weight (~1kg) starting with your arm by your side. Perform 2-3 sets of 12 repetitions two or three times per week. 4. Warm Up. The importance of an adequate warm up cannot be over-estimated. Spend 10 minutes stretching, including a few trunk rotations (Figure 7), and then lightly swinging your club prior to hitting. 5. Don’t perform any exercise or activity that causes shoulder pain. All exercises should be painfree and comfortable to perform. Consult your physiotherapist for advice regarding individual exercise programs. Shoulder pain can be a significant problem for golfers of all ages and ability. The pain can often begin for no apparent reason but gradually worsen over time. Don’t ignore the symptoms! See a qualified health professional who understands the mechanics of the golf swing to ensure your problem is accurately diagnosed and treatment is appropriate for your condition.

Fig 6: Upper back extension stretches

References 1. McHardy, A., Pollard, D., & Kehui, L. (2006). Golf Injuries. A Review of the Literature. Sports Medicine , 36(2):171-187. 2. Kim, D., Millett, P., Warner, J., & Jobe, F. (2004). Shoulder Injuries in Golf. American Journal of Sports Medicine , 32(5):1324-1330. 3. Myers, J., Lephart, S., Yung-SHen, T., Sell, T., Smoliga, J., & Jolly, J. (2007). The role of upper torso and pelvis rotation in driving perfomance during the golf swing. Journal of Sports Sciences , 26(2):181-188. 4. Gosheger, G., Liem, D., Ludwig, K., Greshake, O., & Winkelmann, W. (2003). Injuries and Overuse Syndromes in Golf. American Journal of Sports Medicine , 31(3):438-448.

Fig 7: Upper back rotation stretches using a golf club

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