Less common than other golf-related musculoskeletal injuries, knee injuries can still have a significant affect on a golfer’s ability to play and practice.
I recently had the pleasure of catching up with a friend who was back in Australia taking a break from playing on the Nationwide Tour in the United States. Unfortunately for him, it was an enforced break - he was home to have surgery on his left knee. Less common than other golf-related musculoskeletal injuries, knee injuries can still have a significant affect on a golfer’s ability to play and practice. Ray’s story is a good reminder of the relationship between the physical and the technical aspects of the golf swing.
Ray had a knee injury when playing junior football which he says he made a good recovery from but afterwards found that he could not keep his left foot flat on the ground when making a shot.
Over the past 18 months, however, he has been working on maintaining better foot contact during the swing and keeping his left foot in a relatively neutral position. While he has been really happy with the effect these changes have had on his golf swing, he started to notice pain in the inside of his left knee. This pain gradually worsened and he started to experience swelling around his knee joint. With the more golf he played, the more frequent the episodes of pain and swelling became. Finally Ray had a scan (MRI) which demonstrated a medial meniscal tear. This is when he decided to come back to Australia for surgery. We will come back to Ray’s story but first, some information about meniscal injuries.
Briefly, between the tibia (lower leg) and the femur (thigh), sit two crescent shaped cartilaginous structures called the menisci. The medial meniscus sits on the inside of the knee joint and the lateral meniscus sits on the outside of the joint (see figure from Primal Pictures 2009). The menisci function to help absorb and distribute the loads transmitted through the knee joints during everyday activities, including the golf swing! The menisci also have an important role in knee joint stability, proprioception, (i.e. the ability to sense knee movement), and also have a role in maintaining knee joint nutrition. Any injury to the menisci, then, can impact on the ability of these specialised cartilage structures to perform their function.
Meniscal tears are common and acute tears typically occur when the foot is in contact with the ground, the knee joint is flexed (bent) and the leg is twisted. Degenerative meniscal tears can occur with very little or no trauma at all. The medial meniscus is injured more frequently than the lateral meniscus. This is because the medial meniscus is firmly attached to the medial knee joint capsule making it less mobile than the lateral meniscus. Tears are usually classified according to the size and nature of the tear. For example, the more severe meniscal tears can result in a flap of cartilage interfering with normal knee joint movement. Patients often report clicking and locking with this type of tear. In Ray’s case, he had a large cleavage tear in his medial meniscus and his surgeon also found some degenerative tissue within the meniscus, likely to be a result of his old football injury.
Meniscal injuries and the golf swing
The movement of the knee as well as the forces produced in the knee during the golf swing can result in injuries to the menisci. While the forces through the right knee peak at the end of the backswing, the forces in the left knee are greatest at impact and follow-through 1, 2. During the downswing and follow-through phases of the swing, the pelvis and trunk rotate powerfully towards the left and the golfer’s weight is transferred to the outside border of the left foot, with the lower leg internally rotating and the thigh externally rotating. This means that during these phases of the swing, significant forces are borne by the inside of the left knee and this fits with when Ray was experiencing pain. That is, Ray felt the most pain at impact and it was significant enough for him to have to pull out of several events which was when he decided he needed to seek help.
Some meniscal tears, particularly small tears or degenerative tears, can be managed quite successfully with conservative management. Conservative treatment includes strategies to control the swelling, reduce the pain and improve the range of motion. These strategies include electrotherapy (e.g. ultrasound), ice, manual therapy and, as appropriate, an exercise program to ensure good motor patterns. Eventually, treatment should include exercises designed specifically for the individual golfer, considering the forces that are borne by the knee joint when swinging a golf club as well as those involved with walking the course. In Ray’s case, it was unlikely that conservative management would be successful given the size and nature of the tear. He had an arthroscope to remove the degenerative meniscal tissue and repair the tear.
Ray has had an excellent result. His rehabilitation commenced immediately after surgery. Physiotherapy treatment initially included soft tissue techniques, manual therapy and exercises to optimise muscle activity around the knee and hip. Ray was also able to continue with many of his usual golf specific stretches and upper body resistance exercises during this early phase of his rehabilitation. About 10 days after his surgery, Ray started some light work on the exercise bike and this, as well as his other exercises, was progressed over the next two weeks.
At three weeks after his surgery, his surgeon was happy for Ray to start some swing drills and try 10 short shots on the range. Ray had no problems with this and took himself off and played 14 holes that day! While he did not experience any problems doing this, one of the concerns is that before returning to competitive playing and practicing, a golfer has to have full strength and endurance not only of the knee muscles but of all the muscles up and down the chain in order to minimise the likelihood of irritating or re-injuring the healing meniscus. Nevertheless, Ray continues to be coping well with his rehabilitation and has returned to the United States, assuring us that he will stick with the very stringent program that he has been prescribed!
As always, strategies to minimise the risk for meniscal injuries should be adopted by each and every golfer. Ensuring adequate flexibility of the joints in the lower limb as well as further up the chain may help the lower body optimally absorb and transmit the forces of the swing. Other aspects of golf fitness, particularly optimal motor patterns, are also important. One of the key messages from Ray’s story though, is that despite having a quite a nasty meniscal injury, returning to high level competition is still a very realistic and achievable goal.
Ray Beaufils is a 23 year old golfer who turned pro in early 2009. He has been playing in the US since that time. Ray is coached by Mark Gibson (www.markgibson.com.au). Ray has always been passionate about being fit for golf and maintains a regular fitness regime which includes Pilates exercises, flexibility work and cardiovascular training. Thanks Ray for allowing your story to be told!
1. Gatt Jr CJ et al (1998). Three-dimensional knee joint kinetics during a golf swing: influences of skill level and footwear. Am J Sports Med, 26(2):285-94. McHardy A et al. (2006). Golf injuries: A review of the literature. Sports Medicine, 36:171-87. 2. Hame, SL, Kohler-Ekstrand C, Ghiselli G. (2001) Acute bucket-handle tear of the medial meniscus in a golfer. Arthroscopy. 17(6):E25.