Golf-related spinal injuries and outcomes following spinal surgery

Golf is enjoyed by an estimated 67 million people worldwide and continues to rapidly grow in popularity ¹. So, it is no surprise that doctors and surgeons around the world see many golfers in their clinics and on their operating room tables! In fact, spinal problems are the most prevalent musculoskeletal injury in golfers, representing 55% of all injuries in professional golfers and 35% of all injuries in amateur golfers ².

Further, it is estimated that 62% of all golfers will suffer a golf-related spine injury at some point in their careers ³. Thankfully, the vast majority of these injuries get better with conservative (non-surgical) treatments only, but some can result in more significant problems that eventually require surgery. Indeed, it is well known that several former and current professional golfers have undergone spinal procedures! The question remains, can one return to play at a high level after spine surgery? We all hope the answer to this question is yes! As an example, Tiger Woods won his fifth Green Jacket at the 2019 Masters in dramatic fashion, after his fourth spine surgery, a lumbar fusion procedure.

However, the golf-related outcomes after various spinal procedures remain largely unknown. Here we review some of the reasons why spinal injuries are common in golfers, the literature on the ability of golfers to return to play after various spinal procedures, and what spine surgeons and golfers around the world still need to figure out to get people back onto the golf course!

Why spinal injuries are common in golfers

The modern golf swing has changed dramatically since the silky-smooth deliveries of Ben Hogan and Jack Nicklaus. Before the modern era, players focused on a long backswing followed by a smooth downswing and follow through with relatively minimal separation between the thoracic and lumbar spine (Figure 1)^4,5. However, many current tour pros mimic the motion popularized by Tiger Woods, which focuses on maximizing the rotation of the shoulders and body relative to the hips during the backswing (X factor pattern). This type of backswing allows tremendous torque generation in the lumbar spine, which is then unleashed during the rapid downswing phase which allows a powerful force transfer through the lower extremities, hips, core, and arms, ultimately allowing elite players to generate clubhead speeds over 120 mph. Coupled with advances in club and golf ball technology, and improved sport-specific training and fitness, this has allowed some players to routinely drive the ball over 350 yards and occasionally even over 400 yards! However, the modern golf swing type comes at a cost with regards to golfers’ spines!

Hosea and Gatt have published two studies examining the forces on the lumbar spine during the golf swing ^6,7. They used lumbar spine kinematic and electromyographic (EMG) data that was captured using a combination of surface electrodes and reflective markers over the spinous processes in the thoracic and lumbar spine. They showed that there are compressive loads of up to 8 times a person’s body weight, or 6100 ± 2413 N in amateurs and 7584 ± 2422 N in professionals. Amazingly these are similar to the forces measured in Division I-A college football lineman when hitting a blocking sled (8679 ± 1965 N) ⁸! These large forces place golfers at high risk of soft tissue injury, including muscle and ligamentous strains and facet capsule injury. However, significant injuries to the disks themselves are possible with forces this large. It has been shown that the most common cause of a disc herniation in a healthy disc was lateral bending combined with compression and torsion, which are all significant components of a typical golf swing ⁹. Further, it has been shown in cadaveric studies that disc prolapse can occur with compressive loads of 5448 N ¹⁰. Other injuries that are possible with repetitive injury include stress fractures of the pars interarticularis, spondylolisthesis, and facet arthropathy ¹¹. Ultimately, the human body may not have been designed to perform the modern golf swing and this can predispose to many different injuries, some of which can require surgery.

Return to play recommendations and data after spinal surgery

Although most golf-related spinal injuries do not require surgery, some injuries certainly will benefit from surgical intervention. Most golfers who require spine surgery will need fairly straightforward operations (microdiscectomies, laminectomies, cervical fusions or disc replacements, single-level lumbar fusions). However, the data on return to play (RTP) after these procedures is limited, with a recent systemic review examining RTP after cervical or lumbar fusion only having 3 articles that met the inclusion criteria ¹². AO recently published an excellent summary on the available literature on return to golf after spinal surgery ³. Here we review the available literature on RTP after various spinal procedures.

Microdiscectomy and Laminectomy

• Abla and colleagues surveyed 523 members of the North American Spine Society (NASS) as to their expert opinions on timing of return to golf ¹³. The most common recommended time after laminectomy and microdiscectomy was 4–8 weeks. There was a shorter recommended time for professional and collegiate golfers compared to recreational golfers.
• Eck et al. recommended RTP at 6-8 weeks for non-collision sports and 3 months for collision sports given normal pain relief and range of motion after these time periods¹⁴.
• Watkins’ recommendations are 3 weeks of walking only without bending, lifting, or twisting followed by trunk strengthening and stabilization and gradual transition into sport-specific training with typical RTP at 3 months¹⁵.

Cervical Fusion and Cervical Disc Replacement

• Expert opinion from NASS surgeons recommended RTP 2-3 months after cervical fusion ¹³.
• Richards and colleagues reported a RTP rate of 67.6% after cervical spine surgery (including ACDF, laminectomy, and posterior cervical fusion) ¹⁶.
• There has been no published data or opinions (to our knowledge) on return to golf after cervical disc replacement.

Lumbar Fusion

• Investigators from Rush University performed a survey of 34 patients after 1- or 2-level lumbar fusion surgery. They found that 65% of patients returned to practice and 52% returned to course play. Further, 77% were able to play the same amount or more golf after their surgery compared to before surgery ¹⁷.
• Watkins recommended RTP at 6 months for the older golf athlete ¹⁵.
• Jain and colleagues found that 13 of 13 golfers in their cohort of patients undergoing lumbar fusion eventually returned to golf at an average of 8.6 ± 3.6 months. They had reduced driving distance and increased handicaps post-operatively ¹⁸.
• Many spine surgeons recommend that golfers have radiographic evidence of fusion, resolution of pre-operative pain, and restoration of strength, flexibility, and endurance prior to RTP to prevent recurrent injury and disability ¹⁹.

Future Research

Given its increasing popularity and increased performance demands, there is growing prevalence of spinal injuries related to golf and more golfers that require spine surgery. Although lumbar decompressive operations constitute the majority of spinal procedures performed, to our knowledge there are no studies specifically examining the outcomes of golfers and their overall ability to RTP after a simple lumbar laminectomy or microdiscectomy procedure. Further, the data on RTP after lumbar fusions, cervical procedures, and spinal deformity reconstructions are all limited. This is an area that is ripe for further investigation.
Further, there is a need for objective data regarding swing biomechanics and the kinetics of muscle activation that may help guide surgeons during the post-operative period to help golfers return to the course more rapidly and lessen the risk of further injury.