Scott Webb (Host): Golfing is popular in Florida, as we know, and due to its popularity, injuries are common. My guest today has some tips and advice for how we can prevent many injuries and recover more quickly when we can't avoid them. I'm joined today by Dr. Michael Bodine. He's an Orthopedic Surgeon with BayCare. Welcome to BayCare HealthChat. I'm Scott Webb.

Doctor, it's so nice to have you here today. We're going to talk about golf injuries and prevention. And I know the things that I suffer from, what ails me when I golf. I still do it, but I know what hurts me. Usually my back, my knees, pretty much everything, but let's just start there. Like, what are some of the most common injuries that golfers sustain? What parts of the body do they typically affect and so on?

Michael Bodine, DO: Yes, Scott. I do want to kind of preface things, though. There was a great overview, if our listeners do want to get a little further in terms of detail, out of American Journal of Sports Medicine, they had an article out of Kerland-Jobe, where they looked at common injuries in our golfers.

And one of the things they found, typically these injuries are overuse injuries. That repetitive microtrauma can kind of build up over time and leads to pathology, whether it be in our shoulder or hip, etc. And a lot of it can be exacerbated when we have poor swing mechanics. But when they were looking at both professionals as well as amateur golfers, the top region of our bodies to be injured was the lumbar spine. 

After that, we got more to the upper extremity, the wrist, hand, and elbow. And then third was the shoulder, and me being a sports and shoulder surgeon, that was the area of most interest to me. Ninety percent of those shoulder injuries, involve that leading shoulder. What I mean by that, if you're a right-handed golfer, it's your left shoulder, the one in the front of the swing.

But when I'm in clinic and I have my golfers come in, typically there's five common ailments that they come in with. And we'll just list them off real quick for you. So the one, and I kind of grouped these two together, subacromial impingement and rotator cuff tears or tendonitis. Another would be AC joint arthrosis, and that's essentially just an inflammation of the joint that your clavicle makes with the acromion. The acromion is just an extension of your shoulder blade that meets up with that clavicle, and in certain phases of our swing, it can lead to kind of a narrowing of that joint, or pinching if you will, that can cause pain and inflammation.

Another common pathology that I see is patients coming in with biceps tendonitis. In my younger golfers, some will come in complaining of instability or pain in their swing, and often times that's related to a labral tear. And then the last, sometimes there's golfers out there that may have underlying arthritis in their shoulder joint. And they may have a flare up just from that repetitive motion of the shoulder through the golf swing.

Host: Yeah. That's the thing for me. I know at my age, in my fifties, it's the osteoarthritis is the root cause of things. And then I go out and golf and just sort of exacerbate everything and just, wondering about the signs and symptoms. I mean, is it just if you golf 18 holes, is it just going to be some pain? Are you just going to kind of know like, “Okay, well I did this golfing, obviously.” Like what are the signs and symptoms?

Michael Bodine, DO: Yeah, I think the biggest one, as you alluded to, is pain. That's what drives our patients into the clinic because that's the teller that something's not right, something's going on. And the interesting thing about the shoulder specifically, since that's what we're focusing on, is when the patients complain of pain, they don't always point directly to the shoulder joint itself.

They say, “No, no, it's not my shoulder, it's out on my arm.” And oftentimes that arm pain that they're experiencing is in fact related to the shoulder. And what happens, or the reason that is, is because we have a nerve that travels from our cervical spine, from our neck, that goes down the front of the chest and then dives deep into our armpit, and wraps around the back of the arm and branches out along the side.

And that's our axillary nerve. And that nerve travels in such close proximity to the shoulder that if there's any inflammation or pain within the shoulder due to the underlying injury, that nerve will pick it up and will generate referred pain out to the side of the arm. So that's the most common complaint that happens with patients is the pain, and again, that deltoid referred pain that I explained there.

The other thing is popping and clicking, and that's something I like to tease out, with patients, because popping and clicking by itself, meaning without pain, oftentimes we'll treat this with benign neglect, because there's a multitude of things that can cause popping and clicking in our shoulder that is not necessarily problematic. 

But if they come in and say, “Hey, I'm getting popping, clicking, catching, and it's painful when it happens,” well then a red flag goes up, and in that scenario we're thinking something is in fact getting torn and it's getting caught, and that's why they're having those popping and clicking sensation. The other thing, when I have these patients in clinic and they explain these symptoms, the ones that are really in tune with their golf swing can sometimes even state at what point in the swing does it hurt.

Does it hurt in their initial drawback? Does it hurt at the top of the swing, the follow through? Because that can kind of tease certain injuries in or out. So for instance, if someone's complaining of pain at the top of their backswing in the leading arm, oftentimes this can be a couple things.

So one, they could be getting impingement in the rotator cuff. So what that is, is when that acromion that I described earlier, that projection in the shoulder blade, pinches the rotator cuff between it and the ball of the shoulder joint, which is the humerus. So they can get tears, they can get inflammation in the rotator cuff, they can get bursitis.

And then another thing when it's at the top of the golf swing, is that AC joint that we briefly touched on. As we bring our arm across our chest, that causes the clavicle and acromion to narrow that joint space and kind of pinch upon itself. So that's another area. So just by knowing where in the golf swing they're getting their symptoms can kind of help me hone in as a clinician in terms of where the actual pathology lies.

Host: Yeah, you'd see the value in sort of patient history or patient golf history, if you will. And you mentioned earlier about the repetitive motions is, you know, one of main culprits, if you will, in these injuries. So what can we do to modify our technique to reduce that risk?

Michael Bodine, DO: One, if you can afford and if you have the time, I think, it goes a long way to get a hold of a golf pro or a swing coach, because they're really tuned in and can pick up on the intricacies of your swing and maybe dial into where you're going wrong because if we have any muscular imbalances, that can inevitably change the normal kinematics or motion of our shoulder joint.

And if you keep repeatedly doing that golf swing using the wrong form, you're just going to beat up those structures in the shoulder and develop an injury. So I always like to get patients, if they can afford it to work with a swing or golf pro. And I also like them to work with a physical therapist, again, to pick up on those muscular imbalances.

And some of the things that they'll recommend, just real basics, is to potentially just use a shorter arc swing, so don't go back all the way, don't get into that position where you're going to get the impingement, but you can still keep a straight drive off the tee. The other thing is core strengthening and flexibility. What I mean by core strengthening is I'm looking at areas of the hips, the torso, and the lower legs.

Because if you have good flexibility of your lower body as well as your torso, that can help make up or improve your rotation so you're not relying solely on the shoulder. So that way you may not have to go back all the way to your shoulders, but you're still getting good rotation by using your core muscles, to be able to achieve that adequate swing and power.

Host: Yeah, and I was mentioning to you that I often will, you know, pull into the parking lot, get out of the car, grab my clubs, go right to the first tee, take a couple of practice swings and off we go. And I'm guessing that's not recommended. I'm guessing you recommend some physical conditioning, so how do we do that? What kind of exercises do you recommend?      

Michael Bodine, DO: So far as exercises, especially when we're warming up, before we get out there to play golf, I would recommend both static as well as dynamic exercises. So one critical static exercise that's good to do is to target your pec muscles and that's the doorway stretch. Your pec muscles are one of the more active muscles throughout the entire phase of the golf swing. So that's why I think it's critical to target this one.

And the way you perform the doorway stretch is to put your arms on either side of the door frame and then your chest into the doorway itself and hold that for about 30 seconds. And what I recommend to our patients is to do about three sets of that.

Then the other critical thing is beyond just, you know, your standard static stretch is to do dynamic stretching. And this is great because this kind of wakes up the muscle, gets it activated, and gets some blood flowing to it in addition to stretching the muscle and getting it loose. So, as we mentioned earlier, your core is very active throughout the swing, helps offload some of the stress that your shoulders may incur.

So, one dynamic stretch to wake up your core muscles, which again are your abdomen, your glute muscles, your thighs or hamstrings, et cetera, is something called a walking lunge with a twist. So what you do is if you lunge forward with your right leg, you then twist your torso to the right. And again, this is difficult to visualize. You can look up a video on YouTube or Google.

And then one other dynamic stretch since a lot of the focus of the talk today has been on the shoulders are a number of different exercises that you can do for the periscapular muscles or the muscles that surround the shoulder blade itself. These are critical because they can help offload a lot of the stress that your rotator cuff muscle may incur throughout the swing.

So if anyone's been to physical therapy, they inevitably have seen the different colored rubber bands that are in the office. And I'd recommend getting a low resistance band, so typically yellow and red and even green tend to be your lower resistance bands. And I would focus for two sets of 12 to 15 reps on each exercise.

And what patients can do are external rotation, internal rotation for flexion and abduction. And again, difficult to visualize with just, you know, verbally over the podcast here. But again, YouTube and Google could provide a good illustration of that.

But oftentimes when I have my patients come in and they have an injury, I'm referring them to therapy to work with a therapist. That way they can guide them through these movements. And also we'll provide them illustration on a home exercise program that can help kind of demonstrate these exercise for them with pictures. But again, two sets of 12 on each one of those four motions is a good way to get the shoulder active and warmed up to avoid injury.

And then lastly, once you get out there, do some swings without the club, just going through the motion and then typically work your way up, starting with the wedge, working way up through the irons, the driver, is the safest way to go, gradually increasing, the weighted resistance of the club that you're using to get you warmed up properly before you get out there. 

Host: Yeah. I mean, I think you're right. Like a little stretch probably goes a long way, especially at the beginning of a round. And I want to talk about some of the treatment options. You mentioned you're a surgeon, of course, and let's hope most of us don't end up needing surgery. I mean, I want you to keep your job, of course, but you know, take us through like, from physical therapy, maybe on up, maybe it's injections, before we get to surgery.

Michael Bodine, DO: The vast majority of these soft tissue injuries can be resolved with conservative care themselves. So, yeah, physical therapy is one of the things I always refer my patients to, again, to pick up on those muscular imbalances, improve their flexibility, work on strengthening and conditioning.

In addition to that, there's medications they can take and a lot of these injuries that they sustained are inflammatory conditions, tendinitis, inflammation. So we put them on an anti-inflammatory medication and these are what we commonly call non-steroidal anti-inflammatory drugs.

And those can be purchased over the counter. These are your Motrin, your ibuprofen, your naproxen, etc. There's prescription-based ones as well that work, and we'll prescribe them for different reasons, meloxicam, Celebrex are common ones that I use. And then when things are not responding to those level one medications, we'll call that, sometimes we'll up it and provide them with injections.

And the common injection would be a steroid injection. That's a form of an anti-inflammatory, more potent. And the beautiful thing about the injections is that they are both one diagnostic and two therapeutic. And what I mean by that is when we give our injections, we also include a local anesthetic, similar to what you may give to the dentist when they're numbing up the tooth.

And what that provides is numbing to that area, and if we put it in the correct area, then obviously that's where your pain is at, so it kind of help us confirm our suspicions or diagnoses on what the patient's maybe suffering from. And then the steroid would take effect, and typically, you know, about five to seven days is when that steroid starts to kick in.

That's the typical conservative management, you know, your medications, whether that be oral or injectables, physical therapy, and then avoiding certain motions that cause pain. You may have to step away from the game for some time to allow things to calm down so that way you can recover and heal before you get back out on the course.

Host: Yeah. And then obviously I'm sure in extreme cases, surgery might be indicated, but maybe that's you know, sort of a separate podcast. Let's finish up today and talk about proper equipment selection. You know, I used to think the more expensive the clubs were, the better they would be for me, obviously. The more I looked like the golfers I see on TV, obviously that's going to make me a better golfer.

Just kidding, of course, that's, that's not what happened, but just wondering, when we think about buying clubs, the right type of clubs, can they help prevent injuries?

Michael Bodine, DO: So my brother-in-law, he's a pretty avid golfer. He actually was almost a golf pro at one point. But what he told me, because I was asking him, because I was interested in this question too, the thing with golf is there's not as much equipment as there is in some other sports, but things that they can change, some of the more obvious things, are just the type of club, meaning the type of shaft that you're using.

So you look at the graphite shafts versus stainless steel, stainless steel being heavier, and you know, you pick up a golf club, by itself, it's not all that heavy, but over time, again, that repetitive motion that we've been stressing; things add up. So, if you're having trouble in your swing, it may be better to use that lighter club, that graphite shaft, because that's going to, over time, be less demanding on the body.

You will have to expend less energy. And, like we spoke about earlier, a lot of our injuries can occur either at the beginning or at the end. And the end is due to poor conditioning. So, if you're using a heavier club, using that stainless steel shaft, things build up over time and can fatigue you out and then you get bad form and then next thing you know you have an injury, you're sidelined.

But, you know, whether we treat you conservatively or surgically, and just real quick on surgery, a lot of them can be treated with the exception of arthritis. A lot of them can be treated with minimally invasive approaches, small poke holes in the skin to get into the shoulder joint, repair the injured structure. I think the big thing as we discussed today is, dialing in your swing, making sure you have the proper swing mechanics and warming up before you get out in the course and doing proper rehab. And it's one of those things that even if you do recover from one of these injuries, I can't stress enough how important it is to continue to do your physical therapy exercises.

Inevitably, you can fall back into bad habits, you can redevelop those muscular imbalances that can lead to poor swing mechanics all again. So it's one of those things that even if you do recover from one of these injuries, like the majority of people will, you have to stay true to yourself and keep on with those physical therapy exercises that you're given.

Host: Yeah, that's perfect. Yeah. One of the things I did, I'm 6’4” well, I used to be 6’4” probably more like 6’3” now, but, a little bit of shrinkage, you know, over time, one of the things I did was I had all of my clubs extended like two inches. So just, making my clubs longer helped my posture and it's helped my back in the process. So just a great tip.

Michael Bodine, DO: My brother-in-law, he's roughly around your height. He's 6’6”, I believe, but he did the same thing. And I'm glad you brought that up. He had his clubs extended, fitted for him. Because we come in all shapes and sizes. So definitely.

Host: Yeah. It helped me so much as I'm sure this podcast will help perspective golfers, avid golfers, thank you so much. 

Michael Bodine, DO: No, I appreciate it. Thank you for your time, Scott. And bringing this to the listeners for them to hear.

Host: And for more information, go to BayCare.org. And that wraps up this episode of BayCare HealthChat. Always remember to subscribe, rate and review this podcast and all of the other BayCare podcasts, so we can share the wealth of information from our experts together. I'm Scott Webb. Stay well.