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Abstract
Objectives To determine the golf-related characteristics of spinal injuries among professional golfers in South Korea.
Design Cross-sectional survey study.
Setting Online survey in South Korea.
Participants A total of 439 professional active golfers (226 males and 213 females) in South Korea completed our survey.
Methods Data collected included experiences of cervical (C)-spine and thoracic and lumbar (T/L)-spine injuries, demographics and golf-related characteristics among Korean professional golfers. Logistic regression analysis was used to explore any potential factors of golf-related spinal injuries.
Results A total of 33.7% (148 of 439) experienced total spine injury in professional active golfers, presenting 15.5% of C-spine injuries and 21.9% of T/L-spine injuries. Multivariate logistic regression analysis showed that left-handed (OR, 2.79; 95% CI, 1.20 to 6.47 compared with right-handed) and fingertips <5 cm apart (fair grade) in the shoulder reach flexibility (OR, 0.33; 95% CI, 0.16 to 0.69) significantly influenced spinal injuries. Several factors such as age, golf-career years and body mass index were associated with time to injury, symptom duration and disability of spine injuries including C-spine and T/L-spine injuries.
Conclusions Nearly 33.7% of Korean professional active golfers have experienced golf-related spinal injuries. These injuries appear to make left-handed golfers more vulnerable; however, adequate flexibility may offer protection against such injuries, suggesting the need for tailored preventative strategies based on individual biomechanical profiles.
- Epidemiology
- Spine
- SPORTS MEDICINE
Data availability statement
Data are available upon reasonable request due to ethical issues for sensitive personal information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Our nationwide cross-sectional survey-based analysis was thoroughly conducted for Korean professional active golfers to examine golf-related spinal injuries.
The recruitment strategy through direct communication channels within the Korean Professional Golfers’ Association and the Korean Ladies Professional Golfers’ Association allowed a large sample of active professional golfers in the 2023 season.
The data analysis was based on survey questionnaires, which inherently carry potential limitations associated with the nature of online surveys.
Introduction
Golf is unique among sports due to its distinctive biomechanical demands, particularly regarding the high-velocity, complex golf swing, which engages the entire body.1–3 Prior research, including that of McCarroll in the early 1990s, and later by Hosea and Gatt, has consistently identified low back pain as the most common affliction impacting both amateur and professional golfers, which not only poses a risk to a player’s career longevity but also directly impacts performance metrics such as driving distance and scoring ability.4 5 The importance of addressing injuries in golf cannot be overstated, but comprehensive studies encompassing professional golf players nationwide have been notably absent in the literature.6
High compression, shear, lateral bending and rotational loads that place stress on the lumbar spine during the golf swing motion can potentially lead to lower back pain, which is the result of repetitive and cumulative stress loading.2 It is commonly recognised that compression loads correspond to forces roughly eight times an individual’s body weight.5 7 A significant alternation of the golfer’s biomechanics potentially leads to further injury or a decline in performance, suggesting a clear necessity for targeted research and intervention strategies to fill a significant gap in the current knowledge of spine injury by conducting a comprehensive cross-sectional analysis among golfers at a nationwide level.2
Given the paucity of spinal injuries and their golf-related characteristics among professional active golfers, this study aims to investigate the prevalence of spinal injuries including cervical (C)-spine and thoracic and lumbar (T/L)-spine and determine possible associations between demographics, physical characteristics, training habits and injury patterns among Korean professional golfers who were affiliated with the Korean Professional Golfers’ Association (KPGA) and the Korean Ladies Professional Golfers’ Association (KLPGA).
Methods
Study design and sample characteristics
This nationwide, survey-based and cross-sectional study was conducted in accordance with the current guidelines of a Consensus-based Checklist for Reporting of Survey Studies.8 We recruited active professional golfers registered with KPGA and KLPGA for the 2023 season through direct communication channels within the KPGA and KLPGA, with an emphasis on voluntary participation and confidentiality. Those who did not agree with our survey were excluded from this study. Consequently, a total of 439 participants, comprising 226 KPGA and 213 KLPGA golfers, were finally recruited for this study (figure 1). Informed consent was obtained from all participants prior to survey administration, and the study was approved by the Institutional Review Board of our hospital (IRB number: 2024AN0336).
A diagram and flexibility test inclusion in this study.
Data collection
The instrument included both closed-ended questions for quantitative data and open-ended questions for qualitative insights, particularly regarding injury specifics. The survey instrument was designed to capture a comprehensive range of data including demographic variables such as age, gender, height, weight, body mass index (BMI) and dominant hand. Golf-related characteristics were included as golf-career years, pro-career years, average driver distance, average rounding per week, warming-up hours before rounding, frequency of golf practice, warming-up hours before golf practice, frequency of golf-related stretching and strengths exercise, body trunk shape (triangle, inverted triangle, apple-shaped, rectangular and hourglass-shaped), flexibility (floor touch (no touch, fingertip touched, fist touched and palm touched), shoulder reach flexibility (fingertips ≥5 cm apart, fingertips <5 cm apart, fingertip touched, interlace to finger and touched to palm) and thumb-to-forearm (fingertips ≥5 cm apart from forearm, fingertips <5 cm apart from forearm and touched to forearm)). For participants with spinal injuries, further survey questionnaires were presented including time to injury, symptom duration, disability (defined as sustained pain from injury), cause of injury (repetitive swing, trauma or others) and golf motion relevant to pain (take away, top of the swing, down-swing, impact or follow-through).
Outcome measures
The primary outcome of this study was the percentage of golfers who have experienced spine injuries (spine, C-spine and T/L-spine injuries) and their associations with golf-related characteristics. The secondary outcomes of this study were included as influencing factors for time to injury, symptom duration and disability in professional golfers with spine injuries (C-spine and T/L-spine injuries) and changes in golf activities after spinal injuries.
Statistical analysis
Statistical analyses were performed in Python (V.3.11.5, Python Software Foundation, Wilmington, DE, USA) with Matplotlib (V.3.7.2). Descriptive statistics were presented with mean values and SD for continuous variables and numbers and frequency distributions (percentage) for categorical variables. A normal distribution was confirmed by the Kolmogorov-Smirnov test. After confirming data homogeneity or heteroscedasticity, Student’s t-test (independent) was used for continuous variables, and the χ2 test (nominal data) and Cochran-Armitage test for trend (ordinal data) were used for categorical variables, as appropriate. Logistic regression analyses were conducted to identify influencing factors for spine injuries and time to injury, symptom duration, and disability in professional golfers with spine injuries, presenting the OR or beta (B) with 95% CIs. Statistical significance was set at p<0.05.
Patient and public involvement statement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Equity, diversity and inclusion statement
All active professional golf players affiliated with the KPGA and KLPGA were eligible for participation. This study population facilitated the assessment of both male and female professional golf players in South Korea. However, the findings may not be generalisable to other athlete populations. Future research should consider examining broader populations, including amateur golf players and golfers from regions outside of South Korea.
Results
Baseline characteristics of professional golfers
For the total of 439 professional golfers, the number of males and females was 291 (66.3%) and 148 (33.7%), respectively. Most of the dominant hand was right-handed (n=413, 94.1%). The mean BMI was 24.2 kg/m2 for included professional golfers. The majority of the shoulder reach flexibility and thumb-to-forearm flexibility were fingertip-touched (n=181, 41.2%) and fingertips ≥5 cm apart (n=224, 51.0%), respectively (table 1).
Baseline characteristics of the professional golf players in this study
Experiences of spine injuries in South Korean golf athletes
Golfers who experienced overall spinal injuries, C-spine injuries, T/L-spine injuries, and both C-spine and T/L-spine injuries accounted for 33.7% (148 of 439), 15.5% (68 of 439), 21.9 (96 of 439) and 3.6% (16 of 439), respectively. There was no statistical difference in spinal injuries between KPGA and KLPGA athletes (p>0.05) (figure 2A). Of 251 golfers who experienced musculoskeletal injuries, the total spine, C-spine, T/L-spine, and both C-spine and T/L-spine injuries were 59.0% (60.1% in KPGA athletes, 57.7% in KLPGA athletes; p=0.640), 27.1% (26.5% in KPGA athletes, 27.6% in KLPGA athletes; p=0.115), 38.2% (42.2% in KPGA athletes, 34.1% in KLPGA athletes; p=0.159) and 6.4% (8.6% in KPGA athletes, 4.1% in KLPGA athletes; p=0.142), respectively (figure 2B).
Experiences of musculoskeletal injuries among professional golf players in South Korea. (A) The prevalence rate of musculoskeletal, spine, C-spine, T/L-spine, and both C-spine and T/L-spine injuries among all participants in this study. (B) The prevalence rate of musculoskeletal, spine, C-spine, T/L-spine, and both C-spine and T/L-spine injuries among all participants who experienced musculoskeletal injuries in this study. C, cervical; KLPGA, Korean Ladies Professional Golfers’ Association; KPGA, Korean Professional Golfers’ Association; T/L, thoracic and lumbar.
Risks for spine injuries in professional golf athletes
Left-handed significantly increased the risk of total spine injury (OR, 2.79; 95% CI, 1.20 to 6.47) compared with right-handed. Fingertips <5 cm apart (fair grade) in the shoulder reach flexibility test showed a significantly decreased risk of total spine injury (OR, 0.33; 95% CI, 0.16 to 0.69) compared with fingertips ≥5 cm apart (poor grade). Fingertips <5 cm apart (fair grade) in the thumb-to-forearm test showed a significantly decreased risk of total spine injury (OR, 0.59; 95% CI, 0.37 to 0.93) compared with fingertips ≥5 cm apart (poor grade). The ages between 31 and 40 years (OR, 6.70; 95% CI, 1.72 to 26.14) and between 41 and 50 years (OR, 41.70; 95% CI, 2.21 to 761.70) were associated with a significantly increased risk of C-spine injury, compared with the age under 20 years. There were no significant differences in pro-career years (all p>0.05). Fingertips <5 cm apart (fair grade) in the shoulder reach flexibility test was a significantly reduced risk of total spine injury (OR, 0.28; 95% CI, 0.11 to 0.75) compared with fingertips ≥5 cm apart (poor grade). Left-handed was associated with a significantly increased risk of T/L-spine injury (OR, 3.21; 95% CI, 1.34 to 7.68), compared with the right-handed. Fingertips <5 cm apart (fair grade) in the shoulder reach flexibility test was a significantly reduced risk of total spine injury (OR, 0.26; 95% CI, 0.10 to 0.69) compared with fingertips ≥5 cm apart (poor grade) (table 2).
Multivariate logistic regression analysis for spine injuries
Related factors of time to injury, symptom duration, and disability in C-spine and T/L-spine injuries
For the C-spine injury, the time to injury was significantly affected by age (B, 0.80; 95% CI, 0.21 to 1.38). The symptom duration after the C-spine injury was also significantly affected by age (B, 0.66; 95% CI, 0.16 to 1.16). Meanwhile, the disability after the C-spine injury was significantly associated with BMI (B, 0.08; 95% CI, 0.02 to 0.15). On the other hand, the time to injury for the T/L-spine injury was significantly affected by golf years (B, 0.47; 95% CI, 0.02 to 0.91). Age was significantly associated with the symptom duration (B, 0.49; 95% CI, 0.07 to 0.92) and disability (B, 0.32; 95% CI, 0.08 to 0.56) for the T/L-spine injury (table 3).
Multivariate regression analysis of risk factors for time to injury, symptom duration, and disability in C-spine and T/L-spine injuries
Characteristics between C-spine and T/L-spine injuries and their recognition by golfers
The repetitive swing is the main cause of C-spine (52 of 68, 76.5%) and T/L-spine (82 of 96, 85.4%) injuries with no statistical differences between the two groups (p=0.190), indicating the overuse injury in golfers (figure 3A). The pain relevant to golf motion mainly occurred through follow-through (25 of 68, 36.7%) and top-of-swing (15 of 68, 22.1%) in professional golfers with C-spine injuries. Meanwhile, follow-through (33 of 96, 34.4%), down-swing (20 of 96, 20.8%) and impact (18 of 96, 18.8%) were mainly associated with pain relevant to golf motion. There was a statistical difference in golf motion relevant to pain between the two groups (p=0.030) (figure 3B). The symptoms caused by C-spine (26 of 68, 38.2%) and T/L-spine (36 of 96, 37.5%) injuries frequently persisted for more than 12 months (p=0.618) (figure 3C).
Golf-related characteristics between C-spine and T/L-spine injuries. (A) Cause of spinal injuries, (B) pain relevant to golf motion and (C) symptom duration. C, cervical; T/L, thoracic and lumbar.
Discussion
Our cross-sectional nationwide survey for professional golfers in South Korea demonstrated that nearly 33.7% of Korean professional active golfers have experienced golf-related spinal injuries. Among spinal injuries, T/L-spine injuries were more common than C-spine injuries. We found that left-handedness was associated with an increased risk of spinal injuries. However, adequate flexibility was found to mitigate the risk of such injuries. Specifically, professional golfers aged between 31 and 50 years were particularly vulnerable to C-spine injuries, while left-handed golfers were more susceptible to T/L-spine injuries. Among the professional golfers with spine injuries, it is notable that factors such as age, BMI and golf-career years significantly influence the time to injury, symptom duration and disability of C-spine and T/L-spine injuries.
Low back pain, affirming findings from earlier studies indicating the prevalence of spinal injuries, is the most common source of musculoskeletal injuries for both amateur (16% injuries) and professional golfers (55% injuries).6 9 10 This aligns with past research noting the high incidence of such injuries and the less understood specific mechanisms behind them.11 Indeed, Gluck et al mentioned the notable lack of studies on the true effectiveness of swing modifications for lower back pain in golf.6 McHardy et al described that nearly 16% of Australian amateur golfers experienced golf-related musculoskeletal injuries for 1-year follow-up.12 Of these, the low back is most likely sustained region as a result of the golf swing at the point of impact, followed by the follow-through.12 In our study targeting professional active golfers, nearly 57.2% of included participants responded to experience musculoskeletal injuries, which have the prevalence of T/L-spine injuries (approximately 21.9%), followed by C-spine injuries (approximately 15.5%). The T/L-spine injuries among professional golfers were affected by the golf swing motion of follow-through, followed by impact. Our findings suggested that clinicians need to pay for the swing process (especially follow-through and impact) to prevent spinal injuries.6
Our logistic regression analysis from a comprehensive survey-based cross-sectional study provided intriguing insights into the influence of handedness and flexibility on spinal injuries among professional golfers. The study found left-handed golfers had an increased risk of spinal injuries, particularly T/L-spine injuries, compared with right-handed golfers. This finding suggests that handedness may significantly impact the likelihood of experiencing T/L-spine injuries, potentially due to differences in golf swing mechanics. Meanwhile, flexibility is traditionally an important factor for injury prevention.13–15 Contrary to previous findings, our results suggest that an adequate level of flexibility (classified as a fair grade in this study) contributes to a reduced risk of all spinal injuries, including both C-spine and T/L-spine injuries.13 15 However, flexibility did not result in significant differences in injury risk. These results could imply potential vulnerabilities in golfers with greater joint mobility, possibly due to the high biomechanical loads during golf swings that are exacerbated by increased range of motion. Excessive joint mobility, particularly when not matched with adequate muscular control, can lead to altered stresses on joint tissues during active sports, increasing the risk of repetitive injuries such as ligament sprains and muscle strains.3 4 Hypermobility might be a contributing factor to the T/L spine injuries observed in our study, as well as a potentially modifiable risk factor by reducing the range of motion while golf-swing. Therefore, all golf-related workers including doctors, players and coaches need to focus on the handedness and flexibility of professional golfers to recognise the risks of spinal injuries.
Despite the relatively high incidence of C-spine injuries, current literature has not focused on these injury characteristics among professional golfers.16 In our study, the age range of 31–50 years emerged as the most significant factor associated with C-spine injuries, coinciding with the age group most commonly affected by cervical disc degenerative diseases. Moreover, the time to injury and symptom duration in C-spine injuries were also influenced by age. In contrast, sustained pain from C-spine injuries (defined as disability in this study) was found to be influenced by BMI, highlighting it as a modifiable factor. These findings suggest that C-spine injuries are primarily caused by overuse, particularly repetitive swing, which aligns with our findings on the causes of injury.16 Furthermore, weight control may be necessary to alleviate neck pain in professional golfers who experience sustained discomfort, as BMI was identified as a contributing factor to prolonged symptoms.17
For the T/L-spine injuries in professional golfers, golf-career years were associated with the time to injury, while age was linked to both symptom duration and sustained pain experienced. Like the result of C-spine injuries, T/L-spine injuries are also mainly caused by overuse, particularly repetitive swing. Meanwhile, flexibility showed no statistical difference in time to injury, symptom duration and disability of spine injuries. Therefore, flexibility was associated with the occurrence of spine injuries including C-spine and T/L-spine injuries but did not affect the time to injury, symptom duration and disability.
The prevention of spine injuries in golf is crucial, especially considering the adverse effects they can have on golf performance postinjury. Previous study reveals that both driving distance and functional accuracy from the tee significantly influence scoring efficiency.14 15 The analysis demonstrates that longer tee shots reduce the distance to the pin for the second shot, enhancing the potential for better scores.15 Since driving distance is a crucial element in scoring, it cannot be considered independently of injuries affecting the spine, which evidently compromise performance.2 18 Instead of leveraging their flexibility to achieve a larger backswing, which could increase the risk of injuries, a further biomechanical study could help in finding an optimal swing that minimises risk while maximising performance. This targeted approach could help in developing preventative strategies that are customised to the unique biomechanical profiles of individual golfers, thus reducing the incidence of spine injuries in the sport.
Clinical implications
Our study reinforces the complexity of managing and preventing injuries in professional golfers, highlighting the need for a nuanced approach to training and conditioning. While general fitness, including flexibility exercises, is typically recommended, our findings suggest that there may be a threshold beyond which increased flexibility could become detrimental, particularly for the lumbar spine. This research has opened up several avenues for further investigation, particularly in understanding the biomechanical loads involved in golf swings and their relationship to injury risk. Our study highlights that while optimised practice times, stretching routines and adequate preround warm-ups are essential for all golfers, those with greater flexibility might require tailored approaches. Instead of leveraging their flexibility to achieve a larger backswing, which could increase the risk of injuries, a further biomechanical study could help in finding an optimal swing that minimises risk while maximising performance.
Limitations
This study has several limitations. First, the data analysis was based on survey questionnaires, which inherently carry potential limitations associated with the nature of online surveys, which are likely subject to recall and response bias. Furthermore, we did not conduct a radiological exam for the included professional golfers in this study. Second, although this nationwide survey was conducted in South Korea, it did not capture the entire population of professional active golfers. Third, our sample was limited to professional active golfers, which restricts the ability to identify distinct golf-related characteristics that might be observed in amateur golfers. A comparative analysis including amateur golfers would be necessary to address this limitation. Therefore, future studies that consider these limitations are recommended to further strengthen the findings.
Conclusions
Our nationwide cross-sectional survey-based analysis revealed that nearly 33.7% of Korean professional active golfers have experienced golf-related spinal injuries. These injuries appear to make left-handed golfers more vulnerable; however, adequate flexibility may offer protection against such injuries. Given that most spinal injuries are caused by overuse, a targeted approach that focuses on developing preventative strategies tailored to the unique biomechanical profiles of individual golfers could be beneficial. This approach may help reduce the occurrence of spinal injuries among professional active golfers.
Data availability statement
Data are available upon reasonable request due to ethical issues for sensitive personal information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants. This cross-sectional study was approved by the Institutional Review Board of Korea University Anam Hospital (IRB number: 2024AN0336). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors greatly thank all golfers in KPGA and KLPGA for their participation in this study. This surveys were collected and supported by The Korean Academy of Golf Medicine. We deeply appreciate the cooperation of scientific committee, Kiseong Kim (president) as well as In Ho Choi (advisor) in The Korean Academy of Golf Medicinewho planned and performed for this project.
References
Footnotes
HRL and HJK contributed equally.
D-GC and JHY contributed equally.
Contributors JHY drafted the paper with contributions and approval from all authors. HRL and HJK contributed equally as co-first authors. JHY and D-GC contributed equally as co-corresponding authors. HRL and HJK were involved in the concept and design of the study. HRL, HJK, SL and JHY were involved in the acquisition and analysis of the data. HJK, HRL and JHY wrote the initial manuscript. HJK, HRL, D-GC and JHY made substantial manuscript revisions. JHY accepted full responsibility for the work and conduct of the study as guarantor and controlled the decision to publish. All authors read and approved the final manuscript.
Funding This surveys supported by The Korean Academy of Golf Medicine.
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Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.