This is the sixth in a series of sports medicine articles from the world-renowned Rothman Institute. Series Editors are Rothman doctors Richard H. Rothman MD, and John A. Anderson MD.
As we swing into the warmer months, millions of athletes are perfecting their golf and tennis swings. All too often, these tee times and court times lead to appointment times … most notably in sports medicine physician’s offices.
Despite the advent of high level training techniques, improved nutrition and scientific awareness of orthopedic injuries, there appears to be an increase in musculoskeletal injuries in the professional golf and tennis population over the last two decades. One reason may be that there are more golfers and tennis players on professional tours globally. Secondly, professional golfers and tennis players who play a full season will have less than 2 months off for recovery without taking a break. Thirdly, the age has shifted to a younger population as far as the pro golf and pro tennis tours are concerned. There have been 14-year-old boys who have made the cut at the Masters to a 15-year-old girl winning an LPGA tournament and there have been 15-year-old teenagers who have progressed in the Grand Slam tournaments as well. Sports medicine surgeons believe this trend toward early specialization be a great cause of injury in tennis and golf as well as many other sports.
Finally, there are no breaks from professional golf and tennis in that there are no “substitutes”. Tennis players and golfers do not get paid unless they play and win which is in distinction to baseball players and individuals of other team sports. It is not a team sport. Therefore, you cannot take off from the rotation that day or postpone a match until the next day.
Golf may not involve contact, collision or sprinting, but this gentlemanly sport still commands its own share of injuries. Understandably, football, lacrosse, basketball, and skiing may have higher serious injury rates, but studies have shown that 60% of professional golfers and 40% of amateur golfers suffer either a traumatic or overuse injury while golfing. The majority of injuries in golf are referred to as overuse injuries. The patterns of golf injuries are quite similar between amateurs and professionals with the exception of professionals experiencing more wrist injuries because of the velocity of their golf swing. In all levels of golf, the most common injury is to the low back.
LOW BACK INJURY IN GOLF
This year Tiger Woods withdrew from the Farmers Insurance Open after playing just 11 holes experiencing back pain and grimacing and grabbing his back. Jack Nicklaus and Fred Couples have been plagued by back pain during their long careers. Rocco Mediate, Lee Trevino and Fuzzy Zoeller have resorted to spine surgery. Professional golfers may have excellent swing mechanics but still tend to develop low back pain from overuse. Even a good swing can cause bad problems as human spines were not built for this sport. Amateur golfers can swing a driver from 70 to 90 mph and pros up to about 120 mph. To bring a high velocity golf swing to a stop in around a second puts excessive stress on your back. Hitting 300-400 balls per day with another 150-200 practice swings is a recipe for pain.
The diagnoses typically involve strains and herniated disks in younger golfers and degenerative disk disease in older golfers.
Since recreational golfers often suffer from poor swing mechanics and poor fitness, a combination of physical therapy and golf lessons are typically what the doctor orders. Low back problems in particular appear to be associated with a lack of hip flexibility so Increasing lumbar spine extension and rotation of the lead hip, which is the left leg in right-handed golfers, may decrease stress on the low back. We always recommend that golfers to warm up prior to playing and additional recommendations include core strengthening and the practice of yoga and the use of carts and caddies. Golfers who carry their own bag have twice the chance of back injuries as those who do not carry their bag.
ELBOW INJURIES IN GOLF
The elbow is a very common area for golf related injury as well as for tennis related injury. The term golfer’s elbow is used to describe an injury on the inside or medial side of the elbow. The bone that attaches to the muscles that flex and rotate the wrist is called the medical epicondyle and therefore, another term for golfer’s elbow is medial epicondylitis. This injury involves repetitive stress to the elbow area that results in micro-tearing of the tendon and inadequate healing. Symptoms include pain at the inside of the elbow and difficulty twisting lids and shaking hands. In golf this injury is most commonly seen in the trail arm and it is associated with excessive hooking of the ball or rolling of the wrist in the follow through of the swing.
Although this injury is far more common in the amateur golfer, Tiger Woods incurred a case of medial epicondylitis back in the summer of 2013.
When this type of overuse injury occurs on the outside of the elbow, it is referred to as lateral epicondylitis which typically occurs in the lead elbow of a golfer. The extensor tendons on the outside of the elbow are stressed by the impact of contact and develop micro-tears similar to medial epicondylitis. Lateral epicondylitis is also referred to as tennis elbow because it was commonly seen in the backhand of tennis players. Despite the names, golf and tennis elbow are often seen at the amateur level in both sports, with tennis elbow being far more common overall. Orthopedically, both conditions are treated very similarly with dampening forearm braces, anti-inflammatory medication and physical therapy to include stretching and strengthening exercises. Various types of injections are useful, including the steroid injections as well as PRP injections (Platelet Rich Plasma). Surgery is reserved for those cases that do not respond to conservative care. As a general rule, almost 80 or 90% of people who have the lateral tennis elbow will improve without surgery and about 70% of people who have the medial elbow injury will improve without surgery.
WRIST AND HAND INJURIES IN GOLF
Wrist injuries seem to be primarily the domain of professional golfers. The lead wrist is the most commonly injured with the majority of injuries being tendinitis to the wrist flexors and extensors. However, professional golfers can generate enough force to actually cause fractures of the wrist as well. This year Kevin Stadler withdrew from the Hyundai Tournament of Champions with an hairline fracture of a bone in his left hand.
SHOULDER INJURIES IN GOLF
Another commonly injured area in golfers is the shoulder. In particular, the lead shoulder is far more commonly injured than the trail shoulder. Younger golfers typically have strains and sprains and injuries around the socket of the shoulder referred to as the labral tears. Although amateur golfers are often successfully treated with nonsurgical care, the professionals more often require aggressive treatment. Bud Cauley had surgery to repair a torn labrum in his left shoulder after his first professional victory last year. 18 year old LPGA professional Ariya Jutanugarn, required surgery to repair a torn labrum in her right shoulder last July.
Older golfers are more likely to injure their rotator cuff tendons which often leads to surgical repair. We have personally studied amateur golfers with rotator cuff repairs and have found the results of surgery to be quite successful at this level of competition.
In general, we recommend that all golfers warming up by stretching arms and shoulders and doing some brief cardiovascular exercises prior to playing a round of golf. Strengthening the rotator cuff and scapular muscles through weight resistance is important year round.
HIP INJURIES IN GOLF
During the golf swing, there is extensive stress on the hip due hyperextension and rotation. These forces can injure the ring of tissue around the hip socket called the labrum or they can damage the joint surface and cause arthritis. Labral tears and arthritis are associated with groin pain and outer hip pain. It is very important to adjust your swing to utilize appropriate posture keeping the back straight and the feet planted shoulder width apart and balancing the weight on both shoulders.
Should hip pain be unresponsive to physical therapy and medications, special MRI studies with dye are utilized as a sensitive test to determine whether there may be internal damage that will require surgery. Hip arthroscopy has been a great advance over the last 15 years to get golfers back into the game. Brandt Snedeker sustained a torn labrum and underwent two arthroscopic hip surgeries to return to play.
For the older golfer with painful hip arthritis, hip replacements are an option. Tom Watson, Greg Norman and Jack Nicklaus are famous recipients of this operation and Hal Sutton had both hips replaced and actually advertises his brand of replacement in the media.
Various studies have determined that tennis injury has been estimated at about 5 injuries per 1,000 hours of participation and 33 injuries per 100,000 tennis players. Although almost everyone has heard the term “tennis elbow” there are still many common injuries that occur in other parts of the body as well.
ELBOW INJURIES IN TENNIS
As noted above, tennis elbow and golf elbow occur in both tennis and golf, but tennis elbow is by far the most common elbow condition overall. In tennis, these conditions are due to repetitive stress on the flexor and extensor tendons that attach to the elbow. The medical treatment is the same as noted above in the golf section but we do note some tennis specific recommendations including:
- Increasing grip size with overwrap which decreases sloppy wrist motion
- Decreasing string tension allows a slight trampoline effect, which may take some stress off the elbow (at the expense of losing some control),
- No dead balls and no wet balls
- Consider getting a lesson from a tennis pro regarding stroke production and appropriate grip position of the racket
SHOULDER INJURIES IN TENNIS
As in golf, the most common shoulder injuries include the labrum in individuals under 25 years old and rotator cuff injuries in tennis players over the age of 40. The labrum is the ring of tissue around the shoulder socket that provides stability and is often stressed with serving and overhead shots.
Rotator cuff injuries in the professional tennis population can end a career. The rotator cuff tendon is under great stress as it passes under the acromion bone and that bone can have spurs, which will further irritate the rotator cuff. Although non-operative care is recommended for patients who have irritation or partial tears, surgical treatment is quite often the recommendation for active people with full thickness tears. Fortunately, arthroscopic techniques have evolved in the last 15 years to repair these injuries. Two-time Comeback Player of the Year, Tommy Haas has had rotator cuff surgery in 2014 and also a decade prior on the same shoulder. Andy Roddick has experienced shoulder injuries related to his serve but he has successfully rehabilitated himself without the need for surgery.
PATELLAR TENDON INJURY IN TENNIS
The patellar tendon is the rope that connects the patella to the tibia. It is under great stress in tennis, particularly with quick stops, quick starts, and frequent split stops. This condition involves micro injury to the tendon below the knee cap and results in pain and difficulty with squatting and bending. Recommended treatments include strengthening exercises of the quadriceps muscles called eccentric strengthening. Surgery is rarely indicated for this condition. Although injections are not routinely recommended by sports medicine physicians, certain athletes may choose more aggressive treatment measures. Rafael Nadal has been hampered by this recurring knee problem for half a decade and has utilized platelet rich plasma injections on multiple occasions. PRP injections utilize an individuals own blood product to be injected in the tendon. Although it is not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.
ACHILLES TENDON IN TENNIS
Achilles tendon tears , whether partial (tendinopathy) or complete are far more common in a sports such as tennis than golf. It is the largest tendon in the body and when completely ruptured, it feels as if you were shot or kicked in the calf. This condition is often surgically managed with expected good results and is not a career ending injury.
Achilles tendinopathy or microtears are generally treated nonoperatively, but in high level professionals, may be difficult to eradicate. Dominika Cibulkova will be out of action until the grass court season having recently undertaken surgery to repair a longstanding left Achilles condition that has bothered her for years.
KNEE INJURIES IN TENNIS
Knee injuries including cartilage tears are a big problem for professional tennis players. Quick twists and quick stops and split stops are associated with significant stress on the menisci, which are the cushions between the thigh bone and the shin bone. These cushions have a notoriously poor blood supply and do not heal on their own. Over time, small tears generally will turn into bigger tears. Symptoms include pain, swelling and difficulty with bending, squatting, and kneeling. Meniscal tears often require surgical treatment. Seffi Graf won both the French Open and Wimbledon following knee surgery and pro tennis player Richard Krajicek had returned to tennis successfully after multiple knee surgeries and retired in 2003. Li Na has recently retired after a 15-year tennis career due to "chronic" knee injuries including four knee surgeries and hundreds of shots injected into her knee weekly.
ANKLE INJURIES IN TENNIS
Ankle sprains are certainly seen in tennis, particularly with side to side motion, and not infrequently stepping on a tennis ball. These are generally treated conservatively with expected good results to return to tennis.
BACK PAIN IN TENNIS
Back pain is not as common in tennis as in golf. Low back pain is associated with trunk rotation and hard court playing. The tennis serve in particular extends the lower back and compressing the discs, which are the cushions of the spine. Flexibility and strengthening of the low back are crucial. Tennis specific recommendations include modification of a players serve for more slice and less kick to decrease the arch of the spine. Additionally, lowering a players center of gravity by bending their knees is also useful. Roger Federer and Venus Williams have both withdrawn from tournaments due to a past history of low back injuries and both have recovered without surgery.
Golf and tennis are sports that are easily learnt; though difficult to master. Despite the many potential injuries that may occur, adequate preparation, fitness and technique will keep you playing these sports for a lifetime.
David L. Rubenstein, MD is an orthopedic sports medicine surgeon at the Rothman Institute. He is Head Team Physician for Philadelphia Freedom professional tennis team and also Philadelphia Soul Arena football team. He is also Associate Team Physician for the Philadelphia Phillies MLB Team.
Michael G. Ciccotti, MD is Director of Sports Medicine at the Rothman Institute. He is Head Team Physician for the Philadelphia Phillies MLB Team and St. Joseph’s University and Senior Medical Consultant to the Philadelphia 76ers NBA Team.