November 18, 2011
Upper limb injuries in golfers are of two main types: the less common acute injury caused by an incorrect swing, or the much more frequent injury caused by overuse or exacerbation of an underlying degenerative condition. The latter occurs frequently since the game of golf predominantly involves older people, and these players often present the common pathologies seen in the mature population. It is ironic that many of these problems are seen much earlier due to the unnatural mechanics demanded of the upper limb when performing a golf swing.
Acute hand injuries are unusual in golf, while the development of pain syndromes can be very common, particularly due to underlying conditions of arthritis or tendonitis. Carpal tunnel syndrome is a common nerve compression condition at the wrist level that can become more symptomatic after a long eighteen-hole round. Gripping the golf club can aggravate symptoms typically described as numbness and a cramping sensation in the hand. However, the activity of golf itself does not cause this problem. Initial treatment consists of night splinting, high doses of vitamin B6, or anti-inflammatories. A corticosteroid injection in the wrist is occasionally used, but the usual treatment is surgical. This consists of opening the carpal tunnel, which takes the pressure off the nerve.
Such surgery can be performed through a small incision in the palm of the hand or endoscopically. The endoscopic technique involves the use of a small fiber optic instrument and local anesthesia with almost no postoperative discomfort. An added benefit is that the golfer can return to the links within ten to fourteen days.
Tendonitis of the fingers or wrist usually requires an injection or sometimes a minor surgical release. This condition can be very painful and should be addressed without delay to prevent the development of hand weakness and loss of grip strength.
A forceful grip, like the one seen when a strong hit is given to the golf ball, can greatly exacerbate osteoarthritis. Most typically, this occurs at the base of the thumb and in the last phalanx of the fingers. Mild symptoms can be treated with oral anti-inflammatories, but severe pain and occasional deformity are successfully treated using surgical techniques.
Deep wrist pain is possibly the most typical complaint seen in avid golfers. Such pain is something that the player frequently overlooks or the primary care physician diagnoses inadequately. An evaluation by an orthopedic surgeon is often essential, which will consist of a meticulous physical examination sometimes followed by X-rays and even an MRI. However, when a clear diagnosis or treatment plan is not reached, the athlete should consult a hand and wrist specialist. This is because the complex interrelationship between conditions of bone, ligament, and soft tissues requires an evaluation by a dedicated specialist, who can often save the time and expense of a prolonged diagnostic study that might even be unnecessary.
Wrist pain can be divided into three main regions: radial (the thumb side), central, and ulnar (the pinky side). Simply locating the condition in a specific region can begin to rule out possible causes and diagnoses.
Radial-sided wrist pain is often caused by severe tendonitis known as DeQuervain’s tenosynovitis (or tendonitis), although other types can occur. DeQuervain’s tendonitis can be very disabling but is easily diagnosed through a meticulous physical exam. Eighty percent of sufferers can hope to receive relief from a single, well-placed corticosteroid injection.
A post-traumatic wrist arthritis known as SLAC wrist is also very common and reflects a painful sequela of an old ligamentous wrist injury. For this reason, the timely treatment of ligamentous wrist injuries is of fundamental importance. This late reactive arthritis usually produces radial-sided wrist pain and may require surgical intervention if it is progressive.
Sometimes, radial-sided wrist pain can actually emanate from arthritis at the base of the thumb (basal joint) and therefore requires a thorough radiographic examination of the entire hand. Currently, there are arthroscopic techniques that can relieve this pain and allow the golfer to keep playing. The more aggressive surgical techniques that are more traditional for this region can severely limit the golfer’s return to future play. Arthroscopy now provides a good treatment alternative for this common condition, which is seen most frequently among female golfers.
Central wrist pain can have many more causes. Hitting the turf during an intense swing can lead to a severe ligamentous injury known as a scapholunate ligament tear. Such an injury can often be overlooked on an MRI, hence the importance of an experienced wrist surgeon evaluating the patient. Arthroscopy will often be necessary not only to diagnose the injury but also because it allows for definitive treatment. It is a painless outpatient procedure in which the surgeon inserts a tiny fiber optic instrument into the joint allowing for clear visualization, while small instruments that perform the surgery are inserted through other portals (small incisions). This technique can also be used to remove painful ganglion cysts. These ganglions are benign and occasionally painful masses that can limit the wrist’s range of motion and can also cause weakness. For a golfer, the main advantage would be being able to focus on improving their game as soon as possible, even a week after surgery, depending on what is done.
Ulnar-sided wrist pain is the most common seen in golfers, but fortunately, it is the one that responds most successfully to treatment. The triangular fibrocartilage complex (TFCC) is a thick cartilaginous structure deep inside the wrist, which can tear either in the central part or at its peripheral attachment point. A central tear is usually degenerative in nature and is commonly seen in older golfers, who gradually develop increasing wrist pain. This resembles the meniscus tears seen in the knee and is also treated through arthroscopic debridement. Peripheral tears are detachments of this cartilaginous disc that require suture repair and a period of postoperative immobilization. Current technology allows the repair to be done entirely by arthroscopic means as well. This injury is usually seen in younger players and often occurs from a single incorrect swing. Among the injuries suffered by golfers, TFCC cartilage injuries are perhaps the most commonly overlooked during diagnosis.
Elbow injuries occur much less frequently than wrist problems but can be much more resistant to treatment. The condition known as “golfer’s elbow” is tendonitis at the flexor attachment point on the medial (inner) aspect of the elbow. Although the name relates the condition to golf, it actually occurs infrequently. Treatment usually focuses on a corticosteroid injection and therapy for stretching and strengthening the flexor muscles. Tennis elbow (lateral epicondylitis), whose name is not the most appropriate, is much more common in golfers. This painful condition tends to be persistent and causes pain when the athlete attempts to fully extend the elbow. This can produce limitations in long driving shots where it is necessary to apply force and follow through with the swing to the end. Treatment also focuses on intermittent injections, but it is preferable to avoid more than three injections as tendon weakening can occur as a side effect. Resistant cases may require surgical treatment, which has traditionally been done through an open incision with a potentially long recovery time. Arthroscopic techniques in the elbow are now possible, allowing for a very fast recovery. A newer technology that uses radiofrequency waves to dissolve the painful inflammatory tissue is also possible.
Deep and persistent shoulder pain can affect young and old golfers alike. However, the causes can be very different and require a meticulous diagnostic process in order to understand the underlying problem and reach a solution.
Young and active patients often feel that there is an overuse syndrome. It may be true; however, it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscle, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and, even worse, a mechanical deficiency of the shoulder joint. If it is a chronic problem, without a history of any traumatic event, the patient usually responds to a strengthening therapy protocol that requires diligence on the part of the patient and the therapist.
An acute injury, such as a fall or an impact on a raised arm, can lead to a discrete anatomical injury that may require repair. Such a mechanism is uncommon in a golfer, but the vigorous swing required for a long drive occasionally produces a discrete injury. For this reason, it is of fundamental importance to make a diagnosis, and this is often dictated by the patient’s history regarding the problem. When an acute injury leads to persistent pain, we often order an MRI, which is a diagnostic study that offers better visualization of the soft tissue structures deep in the shoulder. A standard X-ray only allows seeing bone structures and is usually normal in people suffering from shoulder pain syndromes. The MRI can often indicate the severity of the soft tissue injury and can determine whether to continue with conservative treatment (anti-inflammatories, cortisone injection, and therapy) or if surgical intervention is warranted. A true anatomical disorder, such as a labral tear or tendon tear, usually does not improve on its own, hence a mechanical solution may be necessary. Even more than in the previously mentioned joints, arthroscopy is typically used both to diagnose and treat these acute injuries. In truth, open shoulder surgery is rarely done anymore. This minimizes scarring, improves the surgeon’s visualization of the problem, and speeds up recovery. In certain cases, an open incision may be needed depending on the severity and location of the problem. Older golfers often attribute the pain they have in their shoulder to “arthritis.” In truth, arthritis of the shoulder joint (particularly the joint formed by the humeral head and the glenoid cavity) is rather uncommon. Arthritis occurs when the cartilage in a joint wears away, leading to friction between the bones. This osteoarthritis condition occurs more frequently in the knee, hip, or base of the thumb joint, as mentioned earlier, but occurs much less in the shoulder.
The most common cause of shoulder pain in older athletes is known as impingement syndrome. Bursitis is often an element of this syndrome, and this frequently used term is much more accurate to describe the problem than the term “arthritis.” Impingement refers to the mechanical process by which the upper bony arch of the shoulder (acromion of the shoulder blade and the collarbone) puts pressure on or irritates the underlying rotator cuff tendons and bursa. With age, blood flow to the rotator cuff decreases, and small micro-tears of the tendon cause tendonitis, bursitis, and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce bursitis, and shoulder therapy to improve the strength of the intact rotator cuff.
A complete rotator cuff tear means that the torn tendon has separated from the bone and therefore cannot stabilize the humeral head in the glenoid cavity. The patient will be physically unable to lift their arm, or will only be able to do so with severe pain. This entire spectrum of impingement problems is characterized by producing pain when raising the arm, worsening of pain at night, and the inability to lie on the side of the affected shoulder. This will seriously limit a golfer’s game and could allow the player to perform only low, short shots and putts.
Once the pain becomes severe enough without responding to therapy or other conservative means, surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are generally repaired through a traditional open incision. Most repairs require a one-month immobilization period in a sling and several months of postoperative therapy closely directed by the surgeon.
The shoulder is a demanding joint and requires patience from both the patient and the attending surgeon. Recovery is not usually quick; however, strict compliance with the therapy protocol will, in most cases, produce a good result and a functional shoulder free of pain or with minimal pain.
Unlike other sports where lower extremity joints are injured much more frequently, golfers depend on a complication-free harmony of shoulder, elbow, and wrist movement to participate in their passion. For this reason, an upper extremity orthopedic specialist should treat painful conditions without delay to allow the athlete to return to their sport at the best possible level and quickly. News Source: katalystmarketinggroup | Ana Garcia
