Samer Hasan, MD, PhD.

Shoulder and Elbow Injuries

Shoulder and, especially, elbow injuries are common in the amateur and professional golfer. Surveys of both professional and amateur golfers have shown that the elbow is a common site of injury. The elbow accounts for about 10 percent of injuries among professionals.  For the amateur, the elbow accounts for about one in three golf-related injuries. Shoulder injuries are common in certain sports, particularly "overhead" activities such as swimming, baseball, and volleyball. Fortunately, the mechanics of the golf swing are such that the shoulder injury rate for golfers is relatively low. A five-year survey of players on the Senior PGA Tour revealed that the shoulder accounted for about 8 percent of total injuries reported. Other large-scale studies of both pros and amateurs also indicate that the shoulder comprises about 10 percent, or less, of all reported golf injuries.

Although shoulder and elbow injuries during golf cannot be prevented altogether, many can be avoided with attention to proper technique, equipment, and simple maintenance exercise. The following are some common shoulder and elbow injuries that occur commonly during golf, as well as some suggestions on their prevention and treatment.

Elbow Pain

The vast majority of golf-related elbow injuries (for both amateur and pro) are tendon injuries (tendonitis). The most common forms of golf-related elbow tendonitis are golfer’s elbow and tennis elbow. Golfer's elbow is an inflammation, soreness or pain on the inside of the forearm near the elbow. Tennis elbow is a similar condition that affects the outside of the forearm near the elbow. Tennis elbow is actually more common among golfers than golfer's elbow. Golfers often report that pain is greatest at the top of the backswing and at impact. Tennis elbow typically afflicts the left (lead) elbow.

The elbow is susceptible to both tennis elbow and golfer’s elbow at the transition from backswing to downswing. Vigorous muscle contraction and tendon stretching from excessive wrist motion can lead to elbow tendonitis. At impact, the forearm/elbow tendons are also under added stress as they absorb the force of the impact with the ball. The force absorbed by the elbow is even greater if the club strikes the ground or an object.

 Several factors have been identified as risk factors for elbow injuries in golf, including advancing age, faulty swing mechanics, lack of conditioning and insufficient warm-up. Another risk factor is excessive practice or play. For golfers age thirty-five to fifty-five, studies show that playing more than two rounds a week is likely to increase the risk of elbow injury. Advancing age is the only risk factor we golfers don’t have at least some degree of control over.

 The treatment for tennis elbow and golfer’s elbow is typically non-surgical. Rest, including a short respite from golf, if often helpful. Medications, including anti-inflammatories, are helpful in ameliorating symptoms. Other treatment options including stretching exercises and supervised physical therapy and carefully placed cortisone injections. A counterforce brace applied to the forearm and oriented towards the site of greatest discomfort can also work to diminish the strain on the injured tendons. Surgery is reserved to the rare patient who continues to complain of significant pain that has not responded well to the other interventions described earlier.

Certain refinements in technique and changes in equipment can also be helpful in managing elbow conditions. Golfers with elbow problems should consider switching to graphite shafts and low compression balls to decrease elbow strain at impact. They may benefit from practicing on real turf instead of on rubber mats whenever possible. During the swing, easing up on grip pressure and loosening up on the elbows may lessen the elbow pain. The club should be brought back slowly during the backswing and there should be a smooth transition from the backswing to the downswing. Golfers should consider moving the ball to a safe spot when necessary to avoid contact with rocks, tree roots, and sprinklers, and should also consider teeing up the ball on fairway shots, if necessary. A more elliptical swing to sweep the ball off the turf and minimize divot-taking can also be helpful. Finally, the hands should not be released prematurely at the top of the backswing (casting maneuver) and the club should not decelerate before impact.

Shoulder Pain

Shoulder pain in a golfer might be caused by any one of several different underlying conditions. Injury to the all-important rotator cuff tendons accounts for the vast majority of golf-related shoulder injuries. The rotator cuff comprises four tendons that attach around the ball of the arm bone (humeral head) at the shoulder. The rotator cuff tendons act to stabilize the shoulder joint and their muscles provide power during elevation and rotation.

Other common problems include rotator cuff tendonitis, impingement and shoulder bursitis, which are less serious rotator cuff problems than rotator cuff tears, as well as arthritis of the acromio-clavicular ("A-C") joint. Shoulder instability or painful shoulder looseness or the sense of giving way may be present, particularly in the younger golfer. Another problem, related to shoulder instability is the so-called "scapular lag", resulting from weakness of the muscles surrounding the shoulder joint and scapula or shoulder blade.

The majority of injuries, including shoulder injuries, related to the golf swing occur during the impact phase. The force of impact from hitting the ball (called the counterforce) is transmitted up the club to the body. If an object other than the ball is struck by the club head (for example, the ground, a tree, a rock), then the counterforce is greatly increased. Many muscles act together to keep the club head moving forward through the impact phase, effectively overcoming the counterforce. Without these hardworking muscles (which include the forearms, and shoulder rotator cuff muscles), the club would screech to a halt at impact.

For both the professional and the amateur golfer, the likelihood of developing a shoulder injury appears to be due to several factors, including overuse (excessive play or practice), improper swing technique, inadequate warm-up, poor strength and flexibility of the shoulders, arms, back, and legs, and advancing age. It is important to keep in mind that, although golf may not cause too many shoulder injuries, the incidence of shoulder problems, especially rotator cuff problems, increases with age. So, playing the game may aggravate these underlying shoulder problems.

Dr. Hasan is a board certified surgeon specializing in shoulder, elbow, and general orthopaedic problems. Born and raise in New York City, he attended Northwestern University where he majored in Biomedical Engineering, graduating with both honors and research honors.

Dr. Hasan has published over twenty articles in peer-reviewed journals and presented his research efforts at national and international orthopaedic and engineering conferences. He has co-authored two chapters in a major textbook on athletic injuries and sports medicine and,  more recently,  co-authored a chapter in a major textbook on shoulder surgery. He serves as an instructor and lecturer for both the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America.  Since 2001, he has coauthored the review of "What's New in Shoulder and Elbow Surgery" that is published each January in the Journal of Bone and Joint Surgery, the leading orthopaedic journal worldwide.