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So this one is to warm up our legs – this is really important especially if you suffer from any kind of knee pain, it is really important we make sure to warm up those muscles before we go onto the course, but also to make sure we develop power in our swing.

What we are going to do is take one leg forwards, one leg backwards, and hold your club in the opposite hand. All we are going to do is dip down and back up again – just small little mini-split squats using the club just to help you.

We want to make sure the knee doesn’t come over the toe. 2 lots of 5 on each leg – literally 2 minutes.

If you find the split squat one a little bit hard I have got one other for you: So you are going to pop the club in the hands and all we are going to do is a mini little squat.

So we are going to dip, and drive, dip and drive – just to get those legs warm, again pushing the bum backwards, not letting the knees go over the toes.

Again 2 sets of 5.

So this one is now a stretch for your upper body.

What we are going to do is pop the arm across the body, put the hand across – all we are going to do is as we go through there we are just going to rotate around, using the opposite arm to pull you around, hold for a couple of seconds (you should feel this all in your upper back), and relax off.

Then across the other side – pull across and rotate across, hold for a couple of seconds, and relax off.

You can do that twice on each side just once and then move onto your next exercise.

For this last one now, we are going to incrementally increase the speed. We are going to use our five-iron because it is the heaviest club in the bag.

We are going to set up into our swing and we are going to go 3 slow, 3 medium and 3 fast.

You are just going to try to go as fast as you can on the last three before then you take out the club you are going to use on this hole.

So three easy.

Three medium now.

Then three fast to get you nice and warmed up.

That is your warm-up finished – settle yourself down, take the right club and move onto the first tee.

Tonight I am going to present on how being fit for golf is being fit for life. My name is Luke Hart and I am the senior strength and conditioning coach here at UPMC Sports Surgery Clinic.

What I want to talk about is being fit for golf is very much the same as being fit for life and the two go hand in hand. I suppose the reason that this has become such a big issue currently, and has become very topical is that in the last year we have seen the players hitting the ball on the PGA tour further than ever before. People like Bryson DeChambeau have really changed the game of golf, so it is a really prominent feature of everyone’s conversation at the golf club at the moment.

This picture here is from the European tour- and it is the gym that goes with them all around the world. This has been happening for the last couple of years. The gyms are following the players and the players now have access at every single tournament, so they can be lifting weights even while they are at tournaments.

We can see that this is something they are actively partaking. You can see on the left there are the players lifting at the Paris Open – lifting some pretty heavy weights. Then we can see Shane Lowry on the right, again lifting a couple of hundred kilo’s there and really doing his strength and conditioning.

There are a couple of reasons why this has started to become more important. We can see that these methods are not really just for the pros – they are actually for everyday golfers, but also for everyday people. It is not just for the young hitters – we can see here the very young man here in the left picture lifting some serious load. Whilst it is for their golf, it is also very prominent for their health in general.

One of the biggest reasons we should focus on strength and conditioning is because in golf if we are on a tee box with 4 of us – probably 1 of us in the past 12 months has suffered from an injury. The most prominent injuries we see are in the lower back, where we see 25-50% of people have had an injury, in the elbow where we see 9-26% of people have had a golf-related injury and the wrist which kind of links in which is a little bit lower between 11-27%, and lastly the knee where we see between 7-21%. The knee is probably that little bit lower because we can kind of get by with maybe a sore knee and still playing, however playing with a lower back issue, an elbow issue or wrist issue is very hard. So strength and conditioning is really a way to protect against getting these injuries and ensuring that you can stay on the golf course for longer.

As we get older the first things we start to lose our strength and power. So it really makes sense that we really work on these things, especially after the age of about 35 we really see them drop off. It is really important we work on them to make sure that we maintain them as best as we can again not only for our golf but for our general health as well.

WHO  Physical Activity Recommendations

This has really been emphasised by the WHO (World Health Organisation). A couple of years ago they put out there position statement on what we should be doing- what a regular healthy middle-aged adult should be doing. That is 150 minutes of light activity and 75 minutes of vigorous activity. Now you can go 150 minutes of light or 75 minutes of vigorous activity. So most of us here who are playing golf once a week and playing 18 holes have already got the 150 minutes of light activity. Golf is very much considered light activity. Probably the component we are missing is that 75 minutes or some of that 75 minutes of vigorous activity, which really pushes our heart rate up.

The other part is the strength and conditioning component. We can see there that they advocate two strength and conditioning sessions a week. The reason for this is the links between having a good base of strength and being injury-free, and then being free and being able to do cardiovascular work has been shown.

That is a really important thing to distinguish. It also means that we get better health benefits, improved sleep, improved weight, reduced cardiovascular disease and also reduces our back and joint pain as well, so there are lots of benefits from really trying to get as many of these ticked off as we can.

Why is important to do strength work?

So what we are seeing here is why it is important for us to do strength work. So on the left-hand side, we can see a 60-year-old woman and their muscle. What we can see that is the kind of darker component in that picture is the muscle and the white component is the fat. And what we can see is from 60 to 80 we can see quite a significant deterioration between the muscle and the fat and we can actually see some of the fat going into muscle. Underneath that, we can see the graph that shows how much muscle we have and how it changes as we age. After about the age of 30, you can see that there’s a dip off on that line. Now the good news for everyone here is that this doesn’t have to be the case. We can definitely put some strategies in place to stop this from happening. Exactly what the World Health Organisation are recommending.

This picture is showing a 40-year-old triathlete. We can see the muscle is the darker colour and the white is the fat component. Underneath that we can see a 74-year-old sedentary man, so someone who’s doing very little exercise & very little strength conditioning. We can see how that fat has really exponentially increased and has kind of gone into the muscle. But it’s absolutely reversible or changeable.

So underneath, we can then see a 70-year-old triathlete who looks very much the same kind of muscle architecture as a 40-year-old triathlete. We can absolutely take it from maybe not fully from the 74-year-old man to the one underneath- but we can make vast improvements in this just by putting a few small things into our training plan and into our week.

How do I make these changes?

The next question that I get asked all the time is, how can I do it? What’s the best strategy for making these changes? This was a study that was done and what we can see the area that I’ve circled in blue, is when people combine strength training with endurance training, and they got the best and most significant benefits, and it was significantly better than strength alone, and significantly better than endurance alone.

However, strength was better than endurance. So if in doubt, it kind of shows us that we want to improve on leg strength or improve our upper body strength, strength training is definitely the modality that we should use. But actually, including some endurance training as well as some fitness training, probably doesn’t hurt at all either.

Why is being strong important for golf?

I suppose now to relate this back to Golf-why is being strong really important for golf? Well, clubhead speed has been directly linked to players handicaps. So the faster you can swing the club, on average, the better your handicap will be. Improved long game performance has been shown to improve scores and improve the handicap and has been directly linked to clubhead speed. So the higher your clubhead speed, the higher the improved long game and ball distance. However, we’ve got to be able to transfer that obviously into the golf ball as well.

But then the last reason is that when we’re playing golf, golf is actually a very high force high-velocity game actually has similar kind of forces than that of a javelin thrower. And so if we’re not doing any kind of strength conditioning to protect our joints, to protect our muscles, then it’s likely that we’re probably going to have an injury at some point that’s going to keep us out for a while. When we have an injury, we obviously can’t practice and obviously, our golf performance goes downwards.

So another reason as well, why we want to make sure that we can be like the guy on the right here who is swinging the club 133 miles per hour, up there with some of the best, and why we would like to try and be a little bit more like that if we can.

Strength & Conditioning for Golf

So when we’re thinking about strength conditioning for golf, we think about three key areas, we think about rotational strength, we think about lower limb strength and power, and we’re thinking about injury prevention. What we’ve done for you guys tonight is we’ve created a series of warmups and a strength and conditioning session that you could bring in during this lockdown that you can use to kind of improve your strength, improve your overall health and fitness and reduce your injury risk.

And so the warm-up that we’ve created for you is called the Total Tee Box Warm up – the videos are going to be online afterwards for you guys to look up and it’s essential for those times when you’re really late running to the golf club, you’ve got a couple of minutes before you are on the tee, and you’re just watching the other guys tee off before you, and you want to make sure that you’re warmed up so you don’t mess up those first four holes or get injured on those first four holes.

And so it only takes three to five minutes, and it’s everything that you need as a really basic warm-up before you step onto the tee box, and probably something we can all include on those Friday afternoon games when we’re rushing to the golf club.

Sample Strength & Conditioning Plan

Now, this is the sample strength conditioning plan. You can get this at the bottom there’s a link at the bottom of the screen for this. And it’s a six-week strength conditioning plan that you could bring in. Now, as I said earlier, we’ve tried to keep it really simple for you so that you can do all of this at home. There are one or two exercises that you might need the gym for down the line, but I’ve given you some alternatives in today’s presentation that you can use to make sure that you can do this, whilst in lockdown. You’ll be able to get this plan, and you’ll see all the sets and all the reps are on the program so there’s nothing for you to really have to worry about. And I’ve also included some targets.

Now the targets are obviously age and fitness dependent, but just see how close you can get. And lastly, if you’d feel a little bit nervous about doing these exercises, then please contact us, we run strength and conditioning sessions, or we can point you in the direction of someone that you can see, to help you with improving in these areas or maybe giving you a little bit of confidence or technique going into them but we are going to show you all the exercises tonight.

Trap Bar

So the first one that we saw there is a trap bar now this is one of the ones that you might need some gym equipment for. But also you can also do this with anything that you have at home, so I have guys doing this at the moment with dumbbells we have people doing it with bags of books, it’s essentially lifting a weight off the floor and lifting it correctly. And so, my colleague here is lifting it from the front, and from the side.

And the most important thing here to really look at is how he’s using his hips, and his knees, so he’s bending at the hips first before bending at the knees and that’s to make sure that we’re using the hips to lift the weight. The other two things that I want to focus on if you’re doing this at home is making sure that you have a nice neutral flat back, that is not curved, or it’s not overextended, and that your shoulders are sitting roughly in line with your toes.

Now, this is an exercise that using all the pictures I presented tonight, which is why I wanted to show it to you it’s a fantastic exercise. It’s really good for building that explosive strength for your golf. It is called a trap bar and we recommend you kind of do four sets of eight, or five sets of five, depending on what weight you have at home.

Goblet Squat

Now if you don’t have access to that, this is why we’ve included this second exercise called a goblet squat now on this one we’ve shown it with no weights, but you can also include weight and you just hold it on your chest, when you include it with weight.

All we want to do is, essentially, sit back onto a chair. And the reason we want you to use the chair is because it really encourages you to use what we call your posterior chain. Basically, your backside and hamstring muscles, along with your quadriceps on the front of your leg. So you can see here, he is really sitting back onto the chair. We’re making sure the knees don’t go past the toes and his chest, and we can see the badge on his chest is always staying proud.

Again on this one you probably want to do, roughly between four sets of eight. If you can and if it was easy, then you can hold a little bit of weight on the front of the chest, and obviously, for more athletic members in the audience, you can hold some significant weight or eventually when the gyms open back up, you could pop a bar across the chest or on the back to make this one a little bit harder for you.

Split Squat

Now, this is an exercise called a split squat. This is a single-leg exercise, and we know with golf, obviously, we have our back leg, and our front leg, and it’s really important in golf to make sure both the front and the back leg are both as strong as each other. And that’s why we’ve included this exercise and it is a good bit harder than the previous one that I showed you.

There is a couple of really key technical points on this. The first is you will see how we are using the chair to make sure the knee is not going over the toe. All we want you to do is pop your toe underneath the chair to make sure you keep the shin nice and vertical.

The second one is, you can see that my colleague’s chest here is nice and proud and that her back knee is sitting directly underneath her hip. What we don’t want to see is that knee behind the hip, otherwise, that encourages a big arch in your lower back. And this is quite hard so for some people in the audience you might raise the back knee up a little bit, and for others, it might be a little bit easier so you’d hold some weights in your hands. This is where the four-litre bottles of the water from Lidl and Aldi come in very handy.

Wall Squat Hold

This exercise is called the wall hold. Now, this is a fantastic exercise. This is an exercise that everybody can do. We would have everyone from our knee replacements, to our athletic individuals do with this. It is a fantastic one, that shouldn’t cause you too much soreness either. And the aim of this one is four sets of 45 seconds.

Now you’re seeing again on this one that we’ve got a lovely flat back, and you want to imagine you’re pushing your lower back into the wall. The other one is we want vertical shins, again and we want to see the knees in line with toes we shouldn’t see the knees kind of going inside the big toe, or outside of the little toe. And we want to try and hold for four sets of 45 seconds.

Hip Thrust

So the next exercise is the hip thrust. Now, this really is going to work your backside muscles and it’s great for people with lower back pain.

So whereas some of the exercises before this have been all focused on making sure that we develop strength and looking after our knees. This one is now looking after our lower backs. Okay, so it’s a great one for anyone who’s had lower back pain. Three key things that we’re looking for when we watch this video you see her ribs are lovely and flat. Her legs are at 90 degrees, and she’s squeezing her backside at the top of the movement.

And when we do this we really want to make sure like I said that we keep those ribs flat. That is to make sure we don’t have any arch in the lower back, and you should never feel this in your lower back, you should always feel it in your backside muscles. And that’s why it’s going to really help us with our lower back pain because the stronger we can get our backside muscles, the less our lower back should have to do. We also have a slightly harder version to show you, this is where we lift one leg under a single leg so those of you are brave enough you can challenge yourselves on this one, but we’ve really got to make sure the foot is nice and close to the backside and it’s not too far away. Otherwise you’ll feel this in the back of your leg rather than up into your backside muscles.

Band Rotation

So, we’ve looked after the lower back, and we’ve looked after the knees, but now you remember there was that circle, which was kind of encapsulated rotational power.

And so this is a really important one for us golfers, we can build all the lower body strength in the world but if we can’t relate it back to our golf swing then we’re probably going to struggle a little bit, but also this is a great one for building up our core and making sure we’re protecting our lower backs.

So again three key things I want you to work on with this one is making sure your ribs are down or flat, you don’t have a big arch in your lower back – that you have a small range of motion, you shouldn’t be twisting it like your golf club – you should be making sure it’s a much smaller range of motion, but you should be in your golf stance, so if you imagine when you watch my colleague do this one. You should imagine you’re addressing the golf ball with soft knees a little bit of a push back in the hips exactly like you’d be kind of approaching over an iron shot. You can see here that he’s only moving from big toe to big toe so very small range of motion, and that his lower body is staying completely straight forwards. You shouldn’t see your knees or your hips turning. It’s just the upper body that’s doing the work and you should feel it all in your abdomen area. You should very much feel this is a core exercise.

If you are doing this one, and you feel it in your arms. That’s because we’re starting to use the shoulders a little bit too much, and not using our core enough so that’s one little tip to look out for. And this is like I said a fantastic exercise for translating power into our golf swing but also protecting our lower back.

Push Up

We are now going to move on to a little bit of body strength. Now there’s some good evidence that a good upper body does carry over into our golf swing, but also looking after our shoulders, our upper back, our arms, elbows and wrists is really important and doing a little bit of pre-emptive work to make sure that we don’t get any injuries and that’s what this is all about.

So with our push up, quite a common exercise, but we’re just going to go through a few things that we shouldn’t do. So when we’re doing a push up, we shouldn’t see the elbows flare out to the side. We shouldn’t see the lower back sag at all. In fact, if anything, we should see a small curve in the lower back, or that lovely straight line that you can see my colleague here. The second part is you see his elbows are slightly tucked, so they are not chicken winging out. And we’re looking for three sets of eight. Now, for a few people in the audience, this might be a little bit tricky to start with so you can also do the knee variation, where you’re on your knees.

And again, when we do this, we want to make sure our hips aren’t sagging down, because that will actually ensure that we’re using our core and using our lower back muscles to really strengthen them up, and again three sets of eight, and you can gradually progress up to the full variation.

Bicep Curl

Next is our bicep curl. Now, this one you have to be a little bit careful with too much of it is not too great, but also we don’t want to not challenge those muscles at all.

So we just want to do a little bit. So this might be one where you only do it once, maximum twice a week. We don’t want to go too heavy, we want to go nice and light. We’re just looking to stimulate the muscles around the elbow to make sure that we’re working them – so when we do eventually play a little bit more golf maybe we go away on a holiday and play a couple of games in a row, or we go from winter and transitioning to summer, those muscles are strong enough to handle the amount that you’re using and the amount of swinging the golf club.

So a couple of things to look at here and make sure we keep the elbows into the sides. And that we’re not swinging through the lower back it’s very controlled movement, and some people like to stand up against the wall which isn’t a bad idea, but making sure that we keep the weight nice and light to start with, especially if you haven’t done these before.

Wrist Flexion, Extension, Rotation.

The last one that we can do, is the wrist flexion, extension and rotation, and again the exact same caveat, as before we shouldn’t be doing these too often once a week is absolutely fine unless you have an injury in which case you should be guided by your physio on how many to do. We want a nice light weight, so about a kilo or two kilos. If you don’t have the weights then a one-litre bottle of water weighs about roughly one kilo.

And you can see this is the flexion. So this is where the forearm is completely supported – the side of your dining room table is fantastic for this. And we’re just bending the wrist up towards the elbow. The extensions now, where the wrist is coming back towards the elbow and nice and slow and controlled. And again, use this table to support the forearm and nice and light weight in your hands. And the last one which is rotation which is where you’re going to rotate the wrist. So from that position there you rotate the wrist over.

Take away

So with all those exercises there, we have made sure that we looked after four key areas for injury, which was our lower back, our elbows, our wrists and our knee’s. We have also looked at a little bit of rotation, to make sure that the strength work that you are doing carries over into your golf swing, but also that we are working to protect your lower back.

A couple of things I wanted to go through: the first is to take it very slowly. If you have not done any of these exercises before you just want to gradually introduce the exercises want to go from completely doing nothing to doing lots of them because that can raise its own issues. But once you are comfortable, you want to make sure you are progressing forwards. Increasing either the weights or sets when it becomes too easy for you and at the moment with lockdown that can be quite tricky so you might find that you have to be doing a little bit more reps or sets because there may not be more weight.

We see much better results when we are consistent and keeping to a steady amount rather than trying to go from doing not too much to going through every day, or going through 4/5 times a week. So making sure that you bring in good habits now and that you will see out the rest of the year with, will give you much better results.

Fitness Lab

Lastly, we have our fitness lab here, which can help you with all of the things that we’ve spoken about. Now, we’re very lucky that it’s covered by the three big major insurance companies Laya, VHI & Irish Life but it is something that if you’re interested in golf and you’re interested in fitness, or you want to just see where your current fitness levels and health levels are.

We have FitnessLab and we have HealthLab, available, which you may be covered for with your health insurance, but we also offer strength conditioning advice as well. So if you’re interested in learning a little bit more about this maybe testing to see where you’re at, you can email us at [email protected], and we can help you with the program, we can design your own individual program. And we can really help push you forward if that is of interest to you.

Thank you very much.

Click on the links below to download PDFs.

Sample Strength & Conditioning Programme

Mobility & Flexibility Exercises for Golfers

Please note this programme is for sample purposes only and it is recommended you consult your physiotherapist / S&C coach before starting.

Thank you for joining this evening. I am Ann-Maria Byrne. I am a trauma and upper limb surgeon and in UPMC Sports Surgery Clinic I specialise in Elbow, Wrist and Hand surgery. It is a state of the art surgical unit, where we see patients and operate on patients also. I find it a great place to work because I have involvement of a lot of my Sports Medicine colleagues, Physiotherapists and world-class Radiologists as well, and also I have good links with other surgeons who would also deal with sports injuries and things we are going to talk about today. It is one of my favourite places to work.

What I see in my practice is every kind of upper limb injury. Certainly, while the majority of people looking in today will be golfers, you probably do a bit of yoga, you may do some running you may play a bit of tennis as well – and a lot of the injuries we are talking about now will cross over all of these. Of course, when we are looking specifically at the golfers – there are particular injuries that are associated with golfing. While we are mainly talking about the wrist, we can’t ignore the elbow because the wrist and elbow are joined by the forearm and both of them work in tandem. When one is injured it affects the other and vice versa. I always think of it as being a linked joint there between the wrist, elbow and forearm.

What we want to do from this discussion is really look at ways where you can avoid injury and where you can enjoy golf at every stage in your life. I have to say in my defence I am talking today as a surgeon and not a golfer. I do play golf but at a level purely for pleasure rather than for competitiveness – so anybody who is watching who has ever played golf with me or has seen me play golf, remember I am coming from a surgical side this evening. The important thing that we have to think about and look at when we are looking at a golfer is that there is a very specific pattern of swing. You have to take into account obviously the shoulder which we are not talking about today, but the elbow, forearm and the wrist.

The wrist and elbows, each side works in opposite motion paths – one does the opposite of the other. The dominant or trailing upper limb or wrist works more in flexion and extension so its this motion. Whereas the non-dominant, which is the lead wrist and that will be the left side, on a right-handed player, they will be more in rotation, showing rotation, and also ulnar and radial deviation. So when I talk about ulnar sided problems, I am always talking about problems on the little finger side of the wrist and that’s where we see a lot of the injuries on anybody playing golf. I see it in hurlers as well or anybody using a bat or tennis racket or things like that but certainly, in golf, the research has shown that well over 60% of patients will present with ulnar sided wrist pain. And it’s important to take that into account because that is your lead wrist or the non-dominant arm and is related to the biomechanics of the swing, and that’s important in terms of working on your swing physiotherapy later on for upper limb injuries to take that into account.

So the common sites of injury for golfers are obviously what I see the wrist, elbow, shoulder. I don’t look after the neck or lumbar spine, but they’re well-known areas of injuries, and it is all related to swing. Certainly looking at amateur golfers or non-professional golfers over 50% of players will get an injury at some stage during the year. It’s slightly different this year during COVID times because I think people have been playing more often, and then locked down, and then playing again more often. So we’re seeing a different pattern of injury this year, but it certainly is there in the recreational golfers. And then, over 80% of players are presenting with overuse, and this is technique problems causing injury. So these are overuse injuries related to the swing. Acute injuries such as fractures, or hitting the ground and causing acute pain and tendinitis account for about 17%. But over 80% of overuse and technique related issues.

In terms of the recreational players looking at the literature, low back pain is seen in a vast majority with elbow and wrist injuries are way up there as well, and certainly, it’s been found in men, the issues of back pain seem to be more prevalent, whereas in women, there are increased rates of injury to the wrist, elbow and shoulder, and I think that’s related to women trying to get more power behind their swing and trying to get their shots further. With issues with core, then they can cause issues to their wrist, elbow and shoulder because they’re using those preferentially rather than their core. The risk of injury and golf is associated, as I see very much at the moment during COVID, is with increased frequency of play. What we’re seeing is a pattern where people are playing more often and as a result of getting overuse injuries and then there’s a lockdown the golf clubs, unfortunately, are closed. They’re not playing, and then going back to the same level that they were playing at before and getting injuries just as they returned to golf. So the increased frequency of play is associated with recurrent micro-traumas to the upper limbs, tendons and the joints and this causes the injuries.

Also, in people who present with general poor conditioning, so somebody who’s not as fit as they should be, but is out playing there 18 holes of golf, three times a week, and then has back pain or hasn’t worked on their core stability is at increased risk of injury to their upper limb because they’re relying on their upper limb to get their swing, rather than using their core at to actually propel the ball. Patients presenting with decreased flexibility I also find have increased risk of injury, particularly with elbows and wrists. And as people get older, their tendons get shorter and stiffer.

So, younger people who can go off and not stretch, not do their workouts and just go ahead and play – they are the envy of us all. But the rest of us as we get older, unfortunately, have less flexibility, and as a result of this, we can develop further injuries in our tendons, particularly with increased frequency of play. Then looking on the other side at technical issues. Obviously, the poor swing and techniques with poor swing is a big problem I’m going to talk about that later on. Failure to warm up, and we are all guilty of that, I know I’ve jumped out of the car, grabbed my golf clubs, run to the first tee because I’m late for my tee time and haven’t warmed up and I always pay the price later on that day or the next day, where I get my problems in my wrists forearms and elbows. So warming up is something that is absolutely imperative to avoiding injury and ensuring that you get a good play and that you continue on to play long into your later years without injuries, and that’s what we want in golf is to enjoy it and to be able to play from the amateur to competitive golf.

Specific things with golf that you see injuries with are where you’re striking the ground or on rough ground. And then we have to take into account other injuries. So people who have had for example shoulder surgery for maybe dislocation or a rotator cuff injury, and is then returning to golf, they need to look at rehabilitation for all of their upper limb, not just their shoulder, because if they’ve stiffness in their shoulder, they may change their swing and then rely more on their wrist and elbow, and as a result of that, be more at risk of injuries to those sites, and that’s just very disappointing when they’ve come through a period of time away from play for recovery and then to get an injury elsewhere is disappointing. So it’s not just thinking about, you know, if you have a pain in your wrist or elbow, but do you have back pain or shoulder pain, is there something else that is causing you to put increased loads on those other joints, and that has to be addressed as well.

Looking at somebody who has a sports injury, or is wanting to return to sports after an injury, the goals are the same across the board. The first thing is the assessment of the injury or any associated injuries. Assessment of the player’s functional requirements and that changes very much from the player who wants to go out and play nine holes, just for a bit of relaxation like myself, or somebody else who is playing at a very high level competitively, and we need to see what they need to get out of this, and the time that needs to take away to recover. We need to do appropriate investigations so for fractures, the first line is playing x-rays. We don’t always jump in with an MRI scan because it is not appropriate. In other places, an MRI scan or a CT scan may be more appropriate. But this has to be taken into account with an appropriate physical examination because certainly, I have had patients who have come into me who’ve organised scans through various sources and then I’ve had to send them for my own scans because unfortunately, they were the inappropriate investigations so that’s just time wasting for everybody, so appropriate investigations are very important and based on those investigations and the clinical assessment of the injury, we decide on definitive treatment.

After the definitive treatment, then we need to look at what the sport is, in this case, Golf, and then the player-specific rehabilitation. Working on time away from sport and then gradually returning to sport in a safe manner is my aim so that you don’t get problems later on. And then surveillance on the complete recovery and that is throughout all sports injury management- it is the same pattern of treatment there.

So looking specifically at wrist injuries. I mentioned earlier on about swing mechanics – everybody has their own swing. and a lot of us have taken up very bad habits down through the years and we’ve gone to various professionals to try and train them out of us. The one that causes the biggest issue that I see, certainly for the wrist is casting. Casting or scooping is something that is used that comes from fishing. And when you’re fishing you need to use this movement of your wrist to cast off your line, and it is appropriate that’s done in that set setting. However, with golf, when you are bringing your swing down to hit the ball, it is important that the hand reaches the ball, before the club so that the alignment is appropriate.

If you start to engage your wrist and rotate and use this ulnar deviation or casting movement of your wrist, before you hit the ball, it means that the pressure goes up from the ball through the club and into the wrist and it causes problems to the ulnar side of the wrist and as we mentioned that is the side that’s below the little finger there. And you can get tendonitis in the tendon on that side, which is the ECU or extensor Carpi Ulnaris, but I see that in golfers and I see it in hurlers as well, and it is a technique issue with overuse or movement or this casting scooping motion when hitting the ball so, avoiding that type of motion will help – number one, with increasing your power and the distance of your shots, avoiding a high loft, which is not always what is the aim of your shot and decrease the risk of injury. So, avoiding casting is important.

These are just images, again, of the cartilage, which is called the TFCC on that ulnar side of the wrist here. And what I see are people who can have wear and tear changes there, and they may hit a root or hit the ground and get a further injury to the ulnar side of the wrist. This presents with pain- pain on this casting motion or we call it the dart throwers motion and swelling. Usually, I’d organise an MRI scan for this. There are some people who have different shapes of wrists who are more prone to this kind of injury or problem on this side of the wrist. And then, it can flare up every time you hit the ball, and this is usually on the non-dominant side – the leading side, or the leading wrist in a right-handed player – that’d be the left wrist.

Sometimes we have to go in and look at this depending on whether it’s an acute or chronic injury that we’re seeing. Most of the ones that I see are patients who have presented with on and off twinges in their wrist and then have had an acute event, and that kicks everything off and we will talk about treatment later on.

Specific things again that we see with golfers, these are not common injuries, but they are common in golfers, and I see a good few of them. These are where you’re holding your golf club, you hit a piece of rough ground or a root of a tree, and the golf club actually hinges and goes into a bone on this side of the wrist again, the ulnar side of the wrist, called the Hamate, and this has a hook, and beside the hook are your tendons to your ring and little finger and then various arteries, nerves and veins and this can fracture. People come into me with pain and pressure in that region, and they can’t play because of pain. So this is a specific injury that we see that is due to the golf club going into the heel of the hand from hitting the ground.

Other injuries that you see on that that are not acute injuries or fractures, but it is due to compression of the nerves and blood vessels on that side. And again, it’s recurrent microtrauma, and it is due to technique, unfortunately, or grip issues, and oftentimes I would have to explain to people that they will have to change their grip on their golf clubs before they return to full play. Other things that I look at in the wrist and the hand in golfers, and this can happen at any age, and it can happen in patients presenting to me at any level, whether there be amateurs or, professionals – this is tendonitis and arthritis. This usually isn’t specifically related to playing golf, but these are with people who are working in their office, and then maybe going off to the gym to do whatever sport they do there, and then going to play golf or maybe people who had old fractures or injuries, and then are presenting with arthritis.

They wish to play their golf, but they’re having pain. So the ones that I see most commonly are tendinitis in the wrist and I see a lot of tendinitis in the tendons on this side of the wrist, going into the thumb. I’m seeing it more and more related to computer work, texters thumbs. I’m seeing it in young mothers, fathers, and often grannies and grandads who are looking after their grandchildren who are lifting their grandchildren, and they get pressure on the tendons on the outside of the thumb, and as a result of that, they get pain, swelling, and then difficulty with holding the club and pain in their thumb as they go through their swing. That certainly is not specifically related to golf, but it is something that stops people from playing golf, because of the pain in that region.

The other group of people are people who have arthritis and, obviously, this comes to us with too many birthdays. As we get older, everybody’s going to get problems there and again, with playing golf, and with the grip of holding the golf club, you can get pain at the base of the thumb. It’s one of the most common areas to get arthritis, after the hip and knee, and we see it across all walks of life. I see it most commonly in women, and it’s probably related to various jobs that women do in the house that are repetitive going on over the years, where they get pain doing their own buttons, ringing out a dishcloth- the pinch grip is particularly effected and then, unfortunately, holding a golf club that’s an issue as well.

So these are all the areas that I look into that are, again, issues that cause problems with playing golf but these specifically are not particularly related to a golf injury by themselves.

The initial treatments for any problem, whether it be an arthritic problem, a tendinitis problem, a cartilage problem is rest. So it’s taking time away from the sport, or the activity that’s initiating your discomfort and pain. So the first concept is RICE: rest and ice the joint, or the area that’s hurting you. The next thing is to immobilise the joint, and that is to stop the joint from moving. So I just have a picture there of a wrist splint to stop any wrist problems. If there’s thumb or tendon involvement in the thumb, I would use a thumb splint that involves the immobilisation of the thumb as well. And then a short course of anti-inflammatory medications where are appropriate is useful as well. And that is to help with acute injury, pain, and to help any swelling.

Now, obviously, if there’s any evidence of an injury like a fracture, that needs to be investigated further with X- rays and further imaging- that would be a trip to your local emergency department, but certainly most injuries that we see are overuse injuries, unfortunately, and the first line of treatment is rest, and then going into looking at technique further treatments, physiotherapy, rehabilitation, and then possibly down the line surgery is a role.

Unfortunately, I would have a lot of people who come to me who are hoping that there’s a quick fix, with an injection, but what my role is actually to pull back on everything, investigate and make sure that the appropriate regime of treatment is used, but a lot of the time, it is overuse and stopping resting and reassessing the situation and technique is the way to go. With golf in particular, as well as the swing and the technique of swings the golf grips is a big issue, and I do ask people to attend their local club professional for advice with regards to this, to help them improve their golf and avoid injury.

So we cannot just talk about wrist injuries and problems with the rest without talking about elbow as well, because I think one always affects the other it’s you can’t avoid one without the other. And I’m sure you’ll ask why I’m starting off with tennis elbow, and that’s because tennis elbow is way more common in golfers than golfer’s elbow actually is. Tennis elbow affects the leading arm and golf, and this is a pain in the elbow on the outside of the elbow, and it is an overuse degenerative tendon condition. It goes away with rest, but unfortunate if you want to go back and play your golf, you have to learn techniques to avoid recurrent injury to this side.

I see as more and more people who are doing gym work to try and strengthen their arms and their core to help with their game, and particularly in people lifting kettlebells. So I see people who are working on a computer for maybe eight hours a day, all their muscles and their forearms are tightened up/tensed up/shortened and then they go off and do a regime of kettlebells and play golf and unfortunately that is a recipe for disaster where you get tendinitis and pain where you just can’t play the game that you wish.

We see people who do a lot of repetitive wrist rotation as well, who get pressure going up along their forearm, extensor muscles and into the lateral or outside of their elbow, and this causes a lot of problems and discomfort for them as well. Just at the bottom screen there you can see where the tendon is affected on the outside of the elbow there and you can see the black tendon where it’s pulling away or getting micro-tears in the tendon. This doesn’t happen overnight, it’s with time. And unfortunately, it takes time to recover from this as well.

Golfer’s elbow, on the other hand, is on the inside of the elbow, and that is pain and tenderness on this side, and you get radiation along the forearm musculature into your fingers and actually, I see this more commonly in rock climbers than I do in golfers but it can happen obviously in any sports or any activity with overuse. Some people come in and they complain of stiffness as well, and difficulty making a fist because of a pain radiating up onto the inside of the elbow. Some people have weakness in their forearm, hands and wrists that can be related again to overuse, to cam be related to nerve issues and it’s also related to pain, so the pain limits the power that you have in your hands and wrists.

On the inside of the elbow is what everybody will know as their funny bone. So when you hit your funny bone on the inside of the elbow, it is the ulnar nerve, which supplies sensation to the ring and little finger, and you will sometimes feel an electric sensation running down to the ring and little finger and there are people who obviously have medial epicondylitis or golfer’s elbow, but this can also be in association with ulnar nerve issues.

When I’m examining a patient, I will always include this as part of my examination, because people who are not settling down after treatment for medial epicondylitis, or golfer’s elbow must be investigated for the ulnar nerve because they’re so close together, one can affect the other so you can’t rule out issues with that, that are closing and similar symptoms. Some patients present with what’s known as Country Club elbows. This is where you have tennis elbow on one arm, and golfer’s elbow on the other arm. It is always tennis elbow on the leading arm and golfers elbow on the following arm. My main aim with patients presenting like this is to advise on technique modification, and it’s always involving a good tennis professional to guide them on their swing- and sometimes I would send people as well to see our sports and conditioning specialists who will guide them on their swing and guide them on to activities to work on their strength and avoid injury in the future.

I also suggest looking at the grip on their clubs because sometimes the grip is slippy or is not appropriate or the clubs are a wrong length. As a result, this causes them to have a defect in their swing, causing problems for their wrists and elbows. Obviously, it’s easier said than done but avoiding hitting the ground is always a good way to avoid injury to the wrist and elbow. The other option as well when playing is the use of a tennis elbow or golfer’s elbow brace. These are the same thing. They are not a support brace for the elbow. They are a counterforce brace- so what they do is stop the pressure from the rotation and movement of the wrist in travelling up to the elbows causing pain.

So management of any elbow condition, and also a lot of this will treat the wrist, also. So both areas will be treated with this type of regime, is looking at stretching, warm-ups, and eccentric stretching. This is the movement where you’re stretching your forearm musculature to lengthen it and make it stronger, and to make sure that the muscles are nice and long to compensate for any tight, short or unloaded tendons and these are the ones that cause problems with injury. The tennis elbow brace you can see there in the bottom picture and you can see that that position is treating a tennis elbow because that’s the pressure point is protecting pressure going up the arm to the outside of the elbow. You can rotate that to treat golfer’s elbow and use the pressure points on the inside part of the elbow and this is always below the elbow because the pressure is running from the hand and wrist up to the elbow, not the other way round for these type of overuse injuries.

I’m going to mention injections very quickly and there are different types of injections. For tendon injections, there are options of local anaesthetic, steroid or PRP which is activated plasma. Steroid injections are purely for pain relief, they do not cure the underlying inflammatory or degenerative problems with the tendons. I’m very clear to patients when they come into me. This is not a quick fix, unfortunately. Without appropriate rehabilitation, time away from sport, and then a gradual return to sport, they will fail in their treatment regime. So injections are purely for pain relief, not curative for any of these overuse conditions. PRP injections are more invasive in that they do cause an inflammatory reaction around the tendon. This can help the tendon to heal and regenerate because of all the growth factors, and various other factors that are in the plasma that is taken from the patient’s own blood. I always refer patients to my sports medicine colleagues for those injections. These are selected for specific patients, based on their clinical exam and imaging and may not be suitable for everybody, but there are good success rates in the literature for tendinopathy issues.

With regards to the wrist, the research isn’t there with regards to PRP. For pain relief, for TFCC tears, for tendinopathy, again steroid injections are good options, but without adequate rehabilitation, time away from sport and splinting, they alone will not work. In selected patients based on their clinical examination and their scans, surgery is an option. and that varies from patient to patient and what the problem is. There are options in terms of repair of tendons, the release of tendons, nerve release as necessary and treatment for arthritis if necessary as well. These surgical options are there but are very much based on the patient and on a case by case basis.

In terms of exercises- I do, particularly during the lockdown, have a lot of people who have tried to do their own regimes at home and when I talk about working on their core and working on various activities- they go off and they’re doing as much as they can in the gym. But there are specific exercises that do cause issues for the wrist and for the elbows. These are to be limited or avoided- particularly in the early stages after an injury. Obviously with yoga doing any axial loading or leaning on the wrist in this position will put pressure on the ulnar side of the wrist. Also in patients who are doing chin-ups, push-ups or planks that puts a lot of pressure on the flexor muscles, the elbows and the wrists- so these are to be limited or avoided or to be carried out in a controlled environment under the direction of a sports therapist or physiotherapist.

So the take-home message today really so that you can continue to enjoy your golf and to avoid injury is the importance of proper warm-up and stretching. If you have had an injury, and you’re returning to golf and at the moment people are not playing so when you do return to golf and lockdown is lifted, you need to carry out a gradual increase in the length and intensity of play. This is to avoid overuse injuries. Working on general conditioning and core muscle strengthening will definitely help your swing mechanics and avoid injury. If you have an injury to one joint in your upper limb, it’s to be careful in return to play to avoid injuries to your other joints, so it’s about gradually increasing your intensity of play and working on your core strength. Instruction with a golf pro to refine your technique and look at the technique or indeed with our sports specialists is also something to be recommended. Anything that improves your swing improves your technique will certainly increase your enjoyment of your golf, and what you want to be able to do is to enjoy it, injury-free.

Thank you.