The Low Back – Injuries in Golf

Lower back injuries are prevalent in golf. The statistics are clear; if you stand on two feet and play golf, there’s a high probability that your back will hurt. In this installment, we will discuss the disorders of the lower back. While there are many more injuries than listed here, these are the most common.

Disc Injuries: Bulge vs. Herniation
lumbar_disc_herniation2

In the spine there are several important structures: bones (the vertebrae), ligaments, nerves, and intervertebral discs. The main job of the discs is to act as a cushion or shock absorber. The intervertebral discs also give height and flexibility to the spine.

When you think of intervertebral discs you might visualize a jelly donut. There is a soft inner core and a tough outer structure. The outer structure, called the annulus fibrosis, is made of a ligament-like material. The inner mass, called the nucleus pulposus, is very much like the filling in the jelly donut.

A disc bulge is a weakening in the annulus disc. Because of improper loading over many years, the wall of the disc weakens and the nucleus moves into the over-stretched annulus. As the condition or degeneration progresses the annulus continues to stretch until we end up with disc herniations. The major difference between a bulge and a herniation is the extent of the outer ring weakness. A herniated disc, or a ruptured disc, is a more severe problem. It is more difficult to treat and requires surgery more often than a bulging disc.

Most research indicates that disc bulges are not a major source of pain that radiates into the hips and lower extremities. If you are experiencing pain, numbness, weakness, and other symptoms in your lower extremities that is worse when sitting or standing still, with or without lower back pain, the problem might be a herniated disc. In a herniated disc the nucleus material of the disc bulges out beyond the vertebral body and into the canal and can press on the spinal nerves that run into the lower extremities.

Medical research indicates that a position of increased flexion (forward bending) combined with side bending and rotation all together can lead to disc problems. Under normal circumstances the discs in the lower back can withstand several times the body weight in stress without injury or disruption. However, when the annulus is weakened by prolonged improper loading it is prone to injury, including bulges and herniations. Your mother was right when she told you to stand and sit straight. In that position there is normal loading on the discs. This prevents weakening of the annulus and maintains good health in the disc.

Disc injuries from golf seem to be related to excessive flexion of the spine at setup, reverse spine angles, lateral sways, and the like. These positions and movement patterns load the discs in flexion and then the swing superimposes high speed rotation and side bending…a recipe for disaster!

Arthritis

Arthritis is a process of wearing out of the spine. Many attribute this disorder to aging, other injuries, and poor conditioning. All are correct. There is, however, another reason: improper use of the body part, in this case the lower back. If there are muscle imbalances, pelvic girdle imbalances, or a limited range of motion in a hip or thoracic spine, the lower back is put under great stress. An unbalanced pelvis causes asymmetrical loading of the lumbar discs and vertebrae. It will over time lead to weakening of the annular ligaments and wearing out and change in shape of the lumbar vertebrae.

Just because you are older, you do not have to have arthritis. With proper activity including training that promotes symmetry in the pelvis, and the muscles of the trunk it can be mostly prevented. There have been some studies that looked at the relationship between back pain and arthritis. The research was inconclusive except in severe cases of arthritis. Just because your doctor tells you that you have a little arthritis, this does not mean it is the cause of your back pain.

Spondylolesthesis

This is an interesting condition. It is basically a deformity by birth or injury, where the posterior structures of the spine called the pedicles do not form correctly or are fractured. This deformity or fracturing allows slippage of one lumbar vertebra on the one below it. The problem here is that spondylolesthesis can lead to or cause an unstable spine as one vertebra slips on the other. In severe cases it can lead to spinal cord compression. Spondylolesthesis can be progressive, with the slippage increasing over time and with stress or strain. Extension, or backward bending, is a problem for spondylolesthesis sufferers, as it can increase the forward slippage of the upper vertebra on the lower one. Flexion activities are the treatment of choice for this disorder. Once again, muscle imbalances, pelvic girdle imbalances, limited range of motion in a hip or thoracic spine puts the lower back under great stress. An unbalanced pelvis causes asymmetrical loading of the lumbar spine and can aggravate the slippage in spondylolesthesis. In golf, the “S” posture at setup will tend to increase symptoms in spondylolesthesis because this position increases the extension of the lumbar spine.

Facet Impingement

Facet impingement is a challenging diagnosis. The back of the spine has small joints called facet joints. These joints are generally the diameter of your thumb nail in the lumbar spine. The job of the facet joints is to control motion. In the lower back the facet joints allow flexion, extension, and side bending, but are generally thought to prevent lumbar rotation. Once again the “S” posture will be a problem if there is facet impingement.
facets-with-muscles-150x150

Extension of the lumbar spine leads to compression of the facet joints. This, in turn, causes inflammation of the lumbar facets which is the cause of the pain. Facet pain is generally localized to the affected area of the back with little radiation into the legs. Activities such as standing and walking or backward bending are also a problem with this disorder because they create lumbar extension and increase the facet compression.

Typically, there is supposed to be a small backward curve in the lower back. The operative word is “small.” The anatomy texts indicate that eight to ten degrees is considered normal lumbar curve. On most of us that amount of curve is not very noticeable. If you were to put your back against the wall with your feet twelve inches from the wall and stood comfortable you should be able to get your finger tips in the small of your lower back. If you can get your entire hand in there, you might be a candidate for facet joint problems.

Sacroiliac Joint Pain

The sacroiliac joint is the joint at the base of the spine between the sacrum and the pelvis. The sacrum is a series of five fused vertebra at the bottom of your spine. There are two sacroiliac (SI) joints. There is great controversy about whether or not these joints are capable of motion. Our experience suggests that these joints can undergo a small amount of motion (2 to 4 degrees). When one or both of these joints get irritated they can cause pain in the very lower back that might even radiate into your hip joint area.

When out of balance, the muscles that attach to the pelvis, hip flexors, hamstrings, abdominals, and lower back can cause the SI joint to become irritated. If you have SI joint pain you will probably hurt getting out of a chair, standing, walking, or during loading of the hips. In golf this is a real problem because the hips are constantly being loaded when we walk and if we ride a cart and get out of the cart for every shot. This disorder is generally easy to remedy. The remedy only includes restoring normal balance to the muscles of the pelvis and mobility in the hips. It is our experience that the majority of us who have back pain have dysfunction of the SI joint and its associated muscles.
anterior-pelvis-150x150

The bottom line is that self-diagnosis rarely works. If you have back pain you could have any of these disorders. All of these disorders are aggravated by imbalances in the muscles of the pelvis, hips, and lower torso. Remedying these imbalances in most cases will reduce the strain on the structures of the lower back and lead to less pain.

If you have questions about your situation, please send me an email at Paul@BodyBalanceLakeway.com. I will do my best to answer your questions.

Here’s to your healthy back and good golf.

Paul Hendricks, PT, COMPT

Certified Orthopedic Manual Physical Therapist