Golf Injury Research

Knee Injury in Golf

Common knee injuries include those to the Anterior Cruciate Ligament (ACL), the Posterior Cruciate Ligament (PCL), the medial collateral ligament, the meniscii, usually the medial one, Iliotibial band friction syndrome and the breaststroker’s knee.

From Basic Biomechanics by Susan Hall:
Injuries to the ACL are common in sports which involve pivoting. About 70% ACL injuries are from non-contact events, and most are sustained when the femur is rotated on the planted leg, with the knee close to full extension (straightening out) during stopping. These kinds of activities involving sudden changes in direction combined with acceleration or deceleration of the body produce large rotational moments and varus/valgus (same positions as seen in a bow-legged or knock-kneed person, with the knee moving laterally ie. sideways – a job it is not designed to perform) forces at the knee, particularly when such movements are inadequately planned. The ACL is loaded when the net shear (sideways) force at the knee is directed anteriorly. So, for ACL rupture to occur, there must be excess anterior translation or rotation of the femur on the tibia.

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Left Knee:
All of the above could literally have been written to describe Tiger’s knee movements through the downswing (the above is a collection of screenshots from youtube video dated 9 Mar 2012). He has a great deal of knee flexion, and then he loads the knee as he squats, rapidly torques it, and finally goes into full lock-out of the knee past impact! Even though his ACL injuries may not have occurred from golf, they could certainly have been exacerbated by golf.

We know from the systematic review paper, “The Role of Maximizing Distance and Accuracy of Golf Shots” by Patria Hume et al, that only 3 proven biomechanical causes can improve distance and accuracy – the stretch-shorten cycle, ground reaction force and the sequential summation of forces; and only this latter factor simultaneously improves accuracy.
The sequential summation of forces relies on a purely rotational movement of the body – in the transverse plane during both back and through swings – yet most golfers make (and therefore, during the downswing, un-make) sagittal-plane movements of the knee and ankle combined with frontal plane bending of the trunk, during the backswing. Such movements are what add to the compression and change-of-direction inefficiency of the knee joint, as well as a faster movement (to get the knee out of the way of the rest of the body which is trying to rotate) and greater angle to be moved through from excessive-knee-flexion-with-medial-translation to complete extension.

Right Knee:

Fred Funk talks about his total knee replacement surgery with a Stryker knee, following osteoarthritis of the lateral side of his right knee.
Frequent compression of the knee caused by right shoulder dropping down from top of backswing to impact, combined by downward and inward movement of the knee put the knee into a position it is not designed to work best from, especially as the golfer also tries to rotate the trunk while dropping the knee.

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However, people like Tom Watson are telling us regular folks to get the knee in JUST SUCH a position. See his 2008 ‘Right Knee Power Key’ article in Golf Digest Magazine where he tells people to ‘point it to the ball coming down’ and also states that, “Use this image to check your weight transfer: Your right knee should point at or slightly in front of the ball at impact. That shows you’ve made a good shift. Here’s the sequence: Left knee points behind the ball at the top; right knee points toward it at impact”. Image from the article pasted below:

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People in the ‘body-business’ (with even a basic knowledge of anatomy) know that such a valgus force is what causes problems in the knee, combined with constant compressive forces on the outside of the knee from dropping both the knee and body downwards while simultaneously trying to rotate the body.

From Dr Divot’s Guide to Golf Injury comes this useful information:

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From Science and Golf III: Proceedings of the 1998 World Scientific Congress of Golf comes this information:

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IN CONCLUSION, EVERY GOLFER – beginner to best CAN and DOES HAVE POOR-MECHANICS INJURY – it is incorrect to say that the best do it the best way, and that the rest should copy the best.

The ONLY SCIENTIFIC way to make a golf swing is to REVERSE ENGINEER perfect joint positions based on where the club needs to be for solid impact and what the body’s joints ARE CAPABLE of doing, based on their DESIGN.
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Two Elbow Injuries – Tennis (Lateral) and Golfers’ (Medial) Epicondylitis
By Kiran D Kanwar
A Descriptive Paper submitted in partial requirement of the
Masters’ in Sports Science and Nutrition’s
Orthopedics Course
Logan College of Chiropractic

Two Elbow Injuries – Tennis (Lateral) and Golfers’ (Medial) Epicondylitis
This paper will simultaneously describe two different orthopedic clinical conditions, in an
attempt to bring out the differences as well as the similarities between the two conditions, and
finally link the known mechanisms of injury for these two conditions to a likely cause of
microtrauma through ‘poor-mechanics’ as seen in the golf swing.
The two conditions are Lateral (Tennis) and Medial (Golfers’) Epicondylitis of the elbow.
They are conditions of the common extensor or flexor tendon respectively, of the lateral or
medial epicondyle of the humerus. (see Figure 1.)
Definition
The elbow joint is made up of three long bones – the upper-arm humerus proximally and
the forearm radius and ulna distally. Articulating surfaces are the capitulum of the distal humerus
with the radius; and the trochlea of the distal humerus with the ulna.
The distal humerus ends in two epicondyles – the lateral and the medial – and they form
the bony attachment for the muscle-origin of several wrist extensor and flexor tendons
respectively.
The main elbow (humeroulnar) joint is a synovial hinge joint, with freedom in a single
plain. It has good congruence and is well supported by muscles and ligaments, making it a fairly
stable joint. The movements of the elbow joint are extension and flexion. Extension is made
possible by both single and double-jointed muscles, some of which have their origin in the
common extensor tendon on the lateral epicondyle of the humerus. Flexion is similarly aided by
several muscles, some of which have their origin at the common flexor tendon on the medial
epicondyle of the humerus.
Parts of the musculocutaneous, median and radial nerves innervate the anterior aspect of
the elbow, while parts of the ulnar and radial nerve innervate the posterior aspect of the joint.
The proximal radio-ulnar joint is a continuous part of elbow joint, and is of importance
here as it is in part responsible for the forearm movements of supination and pronation.
Injury to the tendon of the Extensor Carpi Radialis Brevis (ECRB) muscle in it’s common
extensor tendon – which area also contains (Jobe, Ciccotti, 1994) the lateral collateral and
annular ligaments, fascia and septum – causes lateral epicondilytis. A commonly used term for
this condition is ‘tennis elbow’. Similarly, injury to the common flexor tendon of the pronator
teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris
causes medial epicondylitis, or, in common parlance, golfer’s elbow.

Tennis Elbow
In an early paper on the subject, James Cyriax (1936) listed 26 published elbow
conditions, and also listed all the authors who agreed that the condition mentioned could be
included as a factor of the vaguely defined term ‘tennis elbow’. For instance, while 32
publications considered ‘traumatic periostitis’ to be a tennis elbow condition, only one author
each considered saturnism, osteomalacia, or osteochrondritis to also be a part of the ‘tennis
elbow’ description.
In 1873, German Physician Dr F Runge, was the first to describe the most common
understanding of the ‘tennis elbow’ or lateral epicondylitis condition – a lesion at the tendinous
origin of the extensor carpi radialis brevis (ECRB) muscle on the lateral epicondyle of the
humerus (Wadsworth, 1987). The lesion typically involves either superficial or deep microscopic
and macroscopic tears (between the ECRB tendon and the periosteum of the lateral epicondyle of
the humerus) , but can also progress to small avulsion fractures, small amounts of calcification
and some degeneration including tendon-rupture.
Tennis elbow is the most common overuse injury of the elbow, according to Carnes and
Vizniak (2010), who also define it in the simplest terms – “lateral elbow pain due to elbow
tendinosis and periostitis”. Tennis elbow is also known as carpenter’s elbow, shooter’s elbow or
archer’s elbow.

Golfer’s Elbow
Golfer’s elbow – or little league thrower’s elbow or pitcher’s elbow (Carnes and Vizniak,
2010), is otherwise known as medial epicondylitis. Lateral epicondylitis occurs 7-20 times more
frequently (Jobe and Ciccotti, 1994), and medial epicondylitis seems to be a milder, less-frequent
condition. It is seen most frequently in sports or occupations in which valgus forces are
frequently placed on the elbow, which creates a stress on the flexor-pronator origin at the medial
epicondyle.

Etiology of Condition (demographics, potential causes, risk factors and biomechanical factors)
Epicondylitis is a tendinitis (in recent times more frequently considered a tendinosis
because of the lack of inflammation) of the muscle-tendons attached to lateral or medial
epicondyles of the humerus (Waugh, 2005). It is often an overuse injury. According to Kannus
(1997), repetitive microtrauma, which is basically repeated exposure of the musculoskeletal
tissue to low-magnitude forces, results in injury at the microscopic level, and no single acute
trauma is normally involved in the pathogenesis of an overuse injury. In chronic tendon
disorders, ‘overuse’ implies that the tendon has been strained repeatedly to 44% strain, at which
stage it is unable to bear any further tensile forces, and thus becomes subject to injury.

Humeral Epicondylitis
In a study (Hamilton, 1986) of 77 patients who presented with humeral epicondylitis in a
busy general practice over a two year period, findings included that epicondylitis is associated
with the dominant hand, and is more frequently seen on the lateral than medial side. This latter
fact could perhaps be ascribed to the fact that treatment is less frequently sought for medial
epicondylitis, as it is often a milder condition than the lateral one. Another factor that was well
confirmed is that humeral epicondylitis – of either side – is a condition prone to relapse.

Tennis Elbow
Cyriax describes an acute (following some violent action) and subacute (seen in a
younger population) tennis elbow following indirect trauma; a chronic occupational condition (in
older persons); and an acute condition upon direct trauma.
The cause of the condition is mostly considered to be idiopathic, but some typical
causative factors include activities in which there is a lot of pronation and supination, with a
fairly extended elbow. Carnes and Vizniak’s text book lists risk factors as including repetitive
eccentric wrist flexion and concentric wrist extension accompanied by supination.
Activities which may be involved include screwing, hammering, ironing and playing the
violin. Surgeons, masseurs, auto-workers, cooks and butchers (American Academy of
Orthopedic Surgeons’ website) are also often prone to this condition. Waldman (2010) also
describes the condition as being seen in those who have to shake hands frequently such as
politicians, or make rapid wrist rotations such as those scooping ice-cream repetitively.
Jobe and Ciccotti (1994) divide the list of causative factors into recreational and
occupational, with lateral epicondylitis being caused by the tennis groundstroke, racquetball,
squash and fencing, along with meat cutting, plumbing, painting, raking and weaving.
Wadsworth (1987), quoted Allander showing an incidence of 1-3% of a population of
15000 subjects, while Kivi was quoted as finding the tennis elbow syndrome in 88 of 7600
manual workers. In most people over 30 years, it is thought to be degenerative in nature.
One Finnish study (Shiri et al 2006), discovered that in a target population of 4783 people
aged 30-64 years, there was a 1.3% prevalence of lateral epicondylitis. Repetitive or forceful arm
movements, and current or previous smoking were shown to be strongly related risk factors
lateral epicondylitis.
The condition (Coonrad et al, 1973) is a very common one, seen 4 times more frequently
in patients in their 40s than in any other decade. People typically presenting with this condition
are between 30 and 50 years old (American Academy of Orthopedic Surgeons’ website),
although it can develop at any age if the activity, unsuitable equipment or poor technique are
responsible.
In tennis, wooden racquets are better able to absorb the vibrations when the ball connects
the racquet, and lighter racquets are better than heavy ones. The tennis elbow is usually seen in
the dominant arm during the backhand stroke of tennis players, and involves elbow extension
along with the incorrect technique (Waldman, 2010) of leading with the shoulder and elbow.
Actually, in the clinical setting, there are more non-athletes than athletes (Wadsworth)
who suffer from the condition, and only 5% of those are actually tennis (or golf) players.

Golfer’s Elbow
The mechanism of this injury involve repetitive flexion of the elbow such as in overhand
throwing activities as seen in baseball/cricket pitching/bowling, the carrying of heavy bags and
making an incorrect golf swing. In other words, frequent wrist flexion along with lifting heavy
weights with the arms far from the body, or abruptly-stopped movement can all be causative
factors. It results from overuse in younger people and degenerative changes in the older
population.
According to the Jobe and Ciccotti (1994) list of causative factors divided into
recreational and occupational: medial epicondylitis may be caused by golf, rowing, baseball
pitching, javelin throwing, tennis serving, along with brick laying, hammering, typing and textile
production.
The Shiri et al (2006) study showed smoking, obesity, repetitive movements and forceful
activities as independent risk factors for medial epicondylitis.

Tennis and Golfer’s Elbow
The Finnish Shiri et al study (2006), discovered that in their target population of 4783
people aged 30-64 years, while there was a 1.3% prevalence of lateral, there was only a 0.4%
prevalence of medial epicondylitis. Prevalence did not differ between men and women and the
most frequently seen age group was 45-54 years.

Clinical Presentation of Condition (history and examination)

Tennis Elbow
Patient history-taking reveals that the pain is at the lateral elbow. It is constant and
becomes worse when the wrist muscles are contracted (Waldman). Patients have difficulty
grasping and lifting objects, especially with an extended arm, and often have sleep disturbed by
pain. Often there is also morning- or after-rest stiffness.
Upon palpation, tenderness or thickening may be felt in the area of the common tendon
on the lateral epicondyle, and there is usually no swelling or inflammation. Both the active and
passive ranges of motion are usually normal, but there is pain upon resisted isometric extension
and supination.

Golfer’s Elbow
Patient history-taking reveals that the pain is at the medial elbow. The condition is
insidious in nature, with gradual onset, and often presents as an aching pain in the medial elbow
region. The pain becomes worse when the wrist muscles are contracted (Waldman). Activity
exacerbates the pain, while rest relieves it. In the chronic condition it can present with constant
pain. Patients often have sleep disturbed by pain, and there is often stiffness upon waking.
Upon palpation, tenderness or thickening may be felt in the area of the common flexor
tendon on or slightly below the medial epicondyle, but there is no swelling or inflammation.
There could be a decreased range of motion when pain is present, and usually there is no
neuropathy involved, although simultaneous ulnar neuropathy is a possibility, as the ulnar nerve
passes superficially in the area of the medial epicondyle.

Diagnosis of Condition (differential diagnoses, special tests, imaging)

Tennis Elbow
Conditions with similar signs and symptoms to lateral epicondylitis include radial tunnel
syndrome involving radial nerve entrapment and radiculopathy from the C6-C7 nerve roots. The
differential diagnosis (Waldman) for the former is that tenderness upon palpation is on top of the
radial nerve while it is more proximal with tennis elbow and directly atop the lateral epicondyle.
Both the similar conditions can be easily differentiated from tennis elbow by using
electromyography.
The simplest and most effective tests which can reproduce a patient’s pain for lateral
epicondylitis, include Mill’s test of forced elbow extension (passive extension of a fully prone
forearm with flexed wrist); attempting to grip and lift an object, particularly with an extended
elbow; extending the wrist or fingers against resistance; resisted wrist extension (Cozen’s test)
when the fingers are loosely bunched together; and resisted extension of the middle finger with
the elbow in extension.
Magnetic Resonance Imaging (MRI), according to Mackay et al (2003), is not only able
to confirm that the Common Extensor Origin (CEO) is the primary site of changes in the ‘tennis
elbow’, but is also useful in separating the often asymptomatic condition of edema from lateral
epicondylitis, based on the presence of tears or thickening.
X-rays help to rule out (Waldman, 2010) elbow arthritis, joint mice or other bony disease
structures; MRIs to rule out joint instability; cervical disc herniation or arthritis; and
Electromyography (EMG) to rule out nerve compression.
Du Toit et al were able to show both true positive as well as true negative chronic ‘tennis
elbow’ situations using power Doppler ultrasound. This technique shows both neovascularity
(not seen in grey-scale ultrasound) as well as the other typical findings of bone spurs or
thickening.

Golfer’s Elbow
Special tests to reproduce the patient’s pain/symptoms include a Reverse Cozen’s and
Reverse Mill’s tests. There may also be a positive valgus test. Conditions with similar signs and
symptoms to medial epicondylitis might sometimes include radiculopathy from the C6-C7 nerve
roots, which may be distinguished by neck pain and upper arm pain, besides that seen in the
elbow. EMG is useful to differentiate golfer’s elbow from a radiculopathy, and X-rays and MRI
make the same distinctions as discussed for the tennis elbow.

Treatment/Management of Condition (including efficacy)

Tennis Elbow
Treatment in the acute phase has included rest, ice, compression, anti-inflammatory
medicines, and corticosteroid injections. In the second-phase treatment has included coordinated
rehabilitation; range-of-motion and strengthening exercises; counterforce bracing; technique-of-
sport-or-activity enhancement and equipment modification (Jobe FW, Ciccotti MG, 1994).
In chronic cases, treatment has also included platelet-rich plasma therapy, surgery and
shock wave therapy Harvard Men’s Health Watch (2012, June).
Treatment in 1936 as reported by Cyriax could involve several modalities. ‘No treatment’
was often effective as the condition could achieve a spontaneous cure within 8 to 12 months.
Wearing a splint to relax the affected muscles took an average of 32 days in 16 subjects. Many
British authors reported finding mobilization beneficial, especially for chronic cases, and this
involved obtaining a click upon manipulation. Cyriax’ Method involved deep friction being
applied to the lateral aspect of the elbow, while it was being held in 90° flexion with a supine
forearm. This massage technique was followed by mobilization of the elbow from fully extended
and supine, to adducted with a sharp varus movement. Cyriax followed several cases, and on that
basis concluded that his method showed the best results, followed by splinting, and that all
surgical interventions were successful, especially if they separated the extensor carpi radialis
brevis muscle from the bone.
Typical treatment today (American Academy of Orthopedic Surgeons’ website) includes
rest (similar to the ‘no treatment’ method mentioned by Cyriax); anti-inflammatory drugs which
are non-steroidal; equipment such as tennis racquets which place less stress on the forearm;
physical therapy modalities such as icing the affected area, ultrasound and muscle stimulation
along with exercises; and the use of a ‘brace’ to relax the affected area.
With regard to exercises, one study of a course of home-exercises by Martinez-
Silvestrini et al (2005), found that stretching alone versus stretching with either eccentric or
concentric strengthening all showed an equal benefit (see Figures 2a and 2b).

Golfer’s Elbow
The most commonly seen treatments for Golfer’s Elbow are similar to the tennis elbow,
especially in the acute phase.
One prospective, randomized, double-blind study assessed the short- and long-term
effects of methylprednisolone in treating medial epicondylitis, on 60 elbows. Although six weeks
after treatment the experimental group showed significantly (p < 0.03) less pain, at three and
twelve months there was no difference between groups, implying that steroidal use only has
short-term benefits in pain reduction for this condition.

Tennis and Golfer’s Elbow
A study by Simunovic et al (1998), showed that low level laser therapy was effective in
the treatment of both lateral and medial epicondylitis, especially in combination with scanner
application techniques, using trigger points.
Coonrad and colleagues obtained follow-up feedback on treatment-results of 339 of 1000
patients of either lateral or medial epicondylitis, and found that of those, 278 responded to
conservative treatment while 39 benefitted from surgery.
Cooper, a physiotherapist, also quotes phonophoresis and ionophoresis as being some of
the useful modalities in the acute (less than 4 weeks) phase.

Research advances, treatment advances, new concepts

Tennis Elbow
According to a recent paper by Behrens et al (2012, May), 70-80% patients see a
disappearance of symptoms within the first year. The authors discuss the benefits of physical
therapy; corticosteroids which might help initially but may harm long-term recovery, and the
modern use of platelet-rich plasma injections, which clinical trials have not proved the efficacy
of. Surgery, when required, has also proved to be beneficial.
Another successful ‘new’ treatment is extracorporeal shock wave therapy (American
Academy of Orthopedic Surgeons’ website), which sends sound waves to the elbow, creating
repeated microtrauma, which supposedly allows the body’s natural curative abilities to kick into
action. This treatment does not as yet have complete scientific evidence. Surgery too, either open
or arthroscopic, is an often-used treatment modality, but comes with the typical risks of any
surgery.
In a study of just a decade ago, Keizer et al, (2002) found that a less invasive treatment
technique of botulimum toxin infiltration could be a good alternative to surgical treatment for the
tennis elbow, as no differences were found in treatment results after two years.
’New’ information on the subject also includes nomenclature. Although the ‘tennis
elbow’ condition has been known for over a hundred years, in recent times, (Waugh, 2005), the
term ‘lateral epicondylitis’ has been rephrased ‘lateral epicondylalgia’ by some, as there is often
no pathology nor any inflammation. The Journal of Orthopedic and Sports Physical Therapy, has,
in 2005, officially adopted the term epicondylalgia (‘algia’ meaning pain) in place of
epicondylitis.
The term ‘tendinitis’ or ‘tendonitis’ is a myth, according to Khan et al (2002), as the
typical tendon-overuse injury has no inflammatory component, and better fits the more-recent as-
of-25-years-ago definition of tendinosis, which can show up after even 2-3 weeks of tendon
insult as frayed collagen fibers. A better term, the authors suggest, would be ‘tendinopathy’ and
anti-inflammatory drugs are not indicated as suitable treatment for the condition.

Golfer’s Elbow
In one study (Krischek et al, 1998), 30 patients presenting with chronic medial
epicondylitis received three sessions, once per week, of 500 extracorporeal shock-wave
impulses. When these patients returned for a 1-year follow-up, only 6 patients were satisfied with
the treatment and the average relief from pain was 32%. The results were much worse than for
identically treated lateral-epicondylitis patients, thus bringing up the concern for whether this
treatment is indeed viable for the medial epicondylitis condition.

Mechanical Causes in Golf and their Prevention
Elbow injury in golf – including both medial and lateral epicondylitis – is common, more
so among amateurs, especially women, according to McHardy and Pollard (2005). They note that
25-33% injuries seen in amateur golfers are elbow injuries, and the figure is 7-10% for
professional golfers. Wrist injury, on the other hand, represents 13-20% of golf injuries among
amateurs, but 20-27% in professionals.

Tennis and Golfer’s Elbow
Common causes as listed by Cooper – a physiotherapist, CSCS and Titleist Performance
Institute (TPI) Certified Golf Fitness Instructor – for both tennis and golfer’s elbow include faulty
swing mechanics*, faulty lower body sequencing*, repetitive stress, increased grip pressure,
decreased grip diameter and stiffer, heavier steel shafts.
One study (Glazebrook et al 1994, Sept.) measured the contraction of the wrist extensor
and flexor muscles during the golf swing, and attempted to study whether contraction reduced
with ergonomic changes. Electromyography was used to record flexor and extensor muscle-
tendon activity during swings of golfers with and without medial epicondylitis. At club-ball
impact, the common extensor muscles produced 58.77% of maximum voluntary contraction
(MVC), while the common flexor muscles showed a ‘flexor burst’ of 90.77% of MVC, and
symptomatic golfers had higher flexor muscle activity (as a percent of MVC) during the set-up
and pre-impact phases of their swings too. The study expected to see a reduction in muscle
activation by providing relief for symptomatic subjects through the use of forearm braces and
larger club-grips, but this was not the case, showing that the methods for relief were not
beneficial.
As can be seen from the abovementioned study, the forearm muscles fire to a great extent
of their full capacity. Whenever (Foster, 2004) the already stressed wrist flexor and extensor
tendons have excessive flexion and extension due to faulty mechanics, they have a greater risk
for epicondylitis. Foster further described that two phases of the golf swing are the most likely
times for injury to occur – the transition from back- to forward-swing; and club-ball contact.
Foster advises golfers – based on typical causes for injury – to use golf clubs with more flexible
shafts; hit balls off grass instead of mats (less jarring impact); loosen grip pressure*; slow down
the backswing to reduce momentum; one-piece start of backswing to avoid extra wrist cock*;
smooth transition*; big-muscle-initiated downswing to avoid ‘casting’*; avoid deceleration,
avoid holding the wrists back excessively* and adopting a more sweeping, elliptical*,
downswing path.

Tennis Elbow
For the present paper, in order to understand the poor-mechanics causes of injury,
especially as they pertain to sport, tennis and golf information was sought. According to the
website of the Nicholas Institute of Sports Medicine and Athletic Trauma, the ‘poor-mechanics’
tennis movements that cause lateral epicondylitis are a) one-handed backhand with the shoulder
high and power being generated from the forearm muscles instead of the entire arm b) late
forehand swing movement – while trying to position the racquet at the last moment – taking
place from the wrists alone, instead of the whole arm, creating a wrist snap c) wrist pronation
with snap when done at great speed during the tennis serve, from the backswing position of tight
extensor tendons in a position of wrist extension/cock with valgus stress on the elbow. Eygendaal
et al also ascribe excessive wrist extension just prior to impact as a cause of tennis elbow.
In golf, according to Foster (2004), the left extensors in the right-handed golfer are more
active during the impact phase, as they keep the wrist rigid during impact.
Cooper – quoting from the Titleist Performance Institute’s Level 1 Manual (a gold-
standard in the golf industry) added that faulty swing mechanics of the lead elbow – which is
usually injured on its lateral aspect – are ‘cupping’ (extending) the lead wrist and ‘chicken
winging’ (elbow flexion with shoulder internal rotation) the lead elbow at impact. This takes
places, according to TPI because of reduced lead arm strength*; less lead shoulder flexibility*
for external rotation; and an over-the-top downswing*. TPI also implicates dysfunctional lower
body and/or trunk* and mobility/stability issues* of the ankles, knees, hips and trunk for the
chicken-wing and cupping.

Golfer’s Elbow
The Nicholas Institute cited poor-mechanics conditions for medial epicondylitis in tennis
as being a)late forehand with quick wrist-snap to bring the racquet forward b) the backward
cocking phase of the serve.
According to Foster (2004) the right-arm flexors in the right-handed golfer keep the right
wrist stable at impact.
Cooper quoting the TPI manual, claims ‘casting’* (summarily losing the set wrist angle
during the downswing) or ‘over-the-top’* (swinging the club on an out-to-in path as it arrives at
the ball) or repetitive use are causative factors of medial epicondylitis. Hitting a hard object on
the ground (root, rock) can also cause this injury. Physical causes for ‘casting’ according to TPI
are poor wrist radial deviation; right wrist extension and left wrist flexion; poor forearm and grip
strength and poor lower body dysfunction including hip mobility, ankle mobility and core/pelvic/
lumbar spine stabilization. Physical causes for ‘over-the-top’ include poor pelvis-to-thorax
separation; poor core stability and poor balance.

A Unique Perspective (based on 17 years of original plus empirical research)
This following section attempts to link ‘poor-mechanics’ epicondylitis injuries to an
‘over-the-top’ (OTT) downswing movement, and present a method for a golf swing which
prevents OTT, thus reducing the scope for all of the ‘faults’ marked with an asterisk in the
preceding paragraphs, and hence also reducing the scope for injury.
Right (for a right-handed golfer) lateral (see Figure 6.) and medial (see Figure 5.) as well
as left lateral epicondylitis (see Figure 7.) can also be ascribed to the ‘poor mechanics’ which
results in an over-the-top downswing movement.
The laws of physics as well as the design of the golf club require the club to arrive at the
ball from a shallow, inside path (see Figure 4.) and thus connect the golf ball below its equator
and on its near (inside) right quadrant.
If the club does not contact the near or inside right quadrant of the ball at impact, it can
be defined as an over-the-top (of the ball) movement. An ‘over-the-top’ movement (see Figure
3.) is one in which the clubhead arrives at the ball from an (see Figure 4.) out-to-in path (away
from the body), as well as an along- or square-to-in path, and therefore the club does not make a
100% flush contact with the ball, on it’s near right quadrant (for a right-handed golfer).
The club can only be delivered to the ball from an ideal, inside path and shallow angle if
the golfer’s left arm acts as the radius of the swing, with the right side staying behind and below
the left, so that it does not take over the role of the leading left arm. At the same time, the lower
body of the golfer must start the downswing with a rotary, transverse-plane movement. The
lower body is followed by the upper body, the arms and finally the club. This movement is
termed an open kinetic chain movement, in which the lower body is able to produce a large
portion of the power for the swing, while the lead arm’s position is able to move the club along
the desired inside path and shallow angle of approach to the ball, for straight direction and ideal
trajectory. A final burst of power is delivered by the right forearm pronating and ‘rolling over’
the left.
At impact, then, the right upper body must trail the lower body; the right trunk must be
laterally flexed; the right shoulder externally rotated; the right elbow extending freely; the right
forearm at least semi-supine and able to go into post-impact supination; and the right wrist only
minimally extended.
If these are not the positions of the joints at the top of the backswing, the golfer needs
perfect timing and sequencing in order to re-position all the major joints during the downswing.
If, at the top of the backswing the golfer has any of the following joint positions,
downswing re-routing will certainly be required, as the joints are in opposite positions of what
they need to be for correct impact:
i. Left side (trunk) in lateral flexion, (usually along with flexed and medially-translated left knee
and dorsi-flexed left ankle). The body requires to generate transverse-plane rotation during the
downswing. That movement is hampered if it is also required to straighten the sagittally flexed
left knee and ankle, and the frontally flexed left-trunk.
ii. Right shoulder abducted past 90 ̊. Such a backswing laterally rotates the scapula, which must
also be returned to its position of medial rotation, on the frontal plane, while the body is
attempting to make a purely transverse plane downswing movement.
iii.Right shoulder in internal rotation. This makes elbow extension during the downswing more
complex, as the elbow is designed to flex on the sagittal plane with external shoulder rotation
iv.Right forearm pronated. This movement always goes together with right wrist extension and
shoulder internal rotation, because the arms try to behave as a closed kinetic chain during the
backswing, with some muscles affecting joints they do not even cross.
v.Right wrist extended. As a golfer attempts ‘wrist-cock’ (wrist radial deviation) during the
backswing, inevitably a good degree of right wrist extension also takes place. The extension is
then simultaneously accompanied by a prone forearm and an internally rotated shoulder, both
of which place the elbow in a difficult-to-straighten-from position
All of the ‘awkward’ joint positions described above, can create, depending on a golfer’s
skill level, and opportunity for an over-the-top (OTT) movement.
It could be said that OTT has two opportunities to take place (similar to Foster’s phases). Phase I
OTT takes place mainly while trying to laterally flex the right trunk, from the left lateral trunk
flexion of the backswing. Downswing movements such as starting the movement with the upper
body; early spinal extension; swaying; casting; and hanging back, (typically ascribed to poor
physical conditioning by Titleist Performance Institute) are actually mostly a result of the body
requiring to re-flex the right side. They represent each golfer’s individualistic compensatory
mechanisms for re-routing the spine from its top-of-backswing left-side flexion, to where it must
be for impact.
Better golfers usually instinctively devise a movement that does not have Phase I OTT,
by starting the downswing in the correct sequence, with the lower body. They might still have a
Phase II OTT movement as they try to re-position joints of the right arm which have been faultily
positioned during the backswing.
This phase of re-positioning is more subtle, more last-minute and can still cause a lot of
inconsistency along with risk for injury. The main ‘bone of contention’ involved in this phase is
the elbow, which is designed to flex and extend easily on the sagittal plane with the shoulder in
external rotation. The golf swing, being a fairly frontal plane movement of the arms, must
present the right arm in external rotation, with the forearm more supine than prone, for an easy
downswing extension of the right elbow.
With little time available in which to straighten the elbow correctly, the better golfer will
make last-minute (Phase II OTT) forearm or wrist adjustments to deliver the club correctly to the
ball (more hand injury in professional golfers according to McHardy et al, 2005), just as the less
talented golfer would simply start the downswing with the upper body (Phase I OTT).
Although the Titleist Performance Institute lists many fitness/physical limitations as the
cause for ‘poor-technique’, it is the contention of this paper that it is basically inappropriate joint
positioning during the set-up and backswing phases of the golf swing which do not leave
sufficient time for several joints to re-position themselves, in correct sequence, in order for
correct lower-to-upper body sequencing to take place.
Figures 4. , 5., and 6. below show how over-the-top positions can result in lateral and
medial right-elbow epicondylitis and left-elbow lateral epicondylitis.
The Minimalist Golf Swing pre-sets the body in thoracic rotation so that the right
shoulder is late in arriving at the ball, thus keeping that shoulder in external rotation more easily.
This pre-set position also permits an un-impeded fully-frontal plane scapulohumeral movement
of both arms. As the swing simultaneously keeps the right trunk laterally flexed throughout the
backswing, phase I over-the-top opportunities are reduced. Neutral wrists and a minimally flexed
right elbow during the backswing help to prevent phase II over-the-top situations. This swing is
thus able to prevent the over-the-top movement at both the downswing phases where it could
occur, and ensure not only correct ball-club contact for ideal ball-flight, but simultaneously
reduced scope for injury.

References
Behrens, S.B., Deren M.E., Matson, A. P., Bruce, B., Green A. (2012). A review of modern
management of lateral epicondylitis. Phys Sportsmed 40(2): 34-40
Carnes, M., Vizniak, N., (2010). Conditions Manual. 3rd Ed., ProHealth Systems.
Coonrad, R.W., Hooper W.R. (1973). Tennis Elbow: Its course, natural history, conservative and
surgical management. The Journal of Bone and Joint Surgery, Vol 55A, No. 6: 1177-82
Cooper, C. Retrieved from website.
http://www.therapeuticassociates.com/wp-content/uploads/Elbow-Injuries-in-Golfers.pdf
Cyriax, J.H., (1936, Oct.) The pathology and treatment of tennis elbow. The Journal of Bone and
Joint Surgery, Vol XVIII, No. 4.:921-940
du Toit C., Stieler, M., Saunders, R., Bisset, L., Vincenzino, B., (2008) Diagnostic accuracy of
power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med
42:872-876.
Eygendaal, D., Rahussen, F Th G., Diercks, R, L (2007). Biomechanics of the elbow joint in
tennis players and relation to pathology. Br J Sports Med 41:820-823
Foster, L. (2004). Dr. Divot’s Guide to Golf Injuries. Dr Divot Publishing Inc.:10-12
Glazebrook, M.a., Curwin, S., Islam, M.N., Kozey, J., Stanish, W.D., (1994, Sept.) Medial
Epicondylitis – An Electromyographic Analysis and an investigation of Intervention
Strategies. The American Journal of Sports Medicine. Vol. 22-5: 674-679.
Grana, W., (2001, July). Medial Epicondylitis and cubital tunnel syndrome in the throwing
athlete. Clinics in Sports Medicine. Vol 20, Issue 3:541-48
Hamilton, P.G.(1986). The prevalence of humeral epicondylitis: A survey in general practice.
Journal of the Royal College of General Practitioners. 36: 464-465
Jobe, F. W., Ciccotti, M.G. (1994). Lateral and Medial Epicondylitis of the elbow. J Am Acad
Orthop Surg Vol 2 No 1:1-8
Kannus, P. (1997, Apr.). Etiology and pathophysiology of chronic tendon disorders in sports.
Scandinavian Journal of Medicine and science in Sports. Vol 7, Issue 2: 78-85
Keizer, S.B., Rutten, H.P., Pilot, P., Morre, H., Os, J.J., Verburg, A.D. (2002, Aug).
Botulinum Toxin injection versus surgical treatment for tennis elbow: a randomized pilot
study. Current Orthopedic Practice, A Review and Research Journal Vol 401:125-131
Khan, K.M., Cook, J.L., Kannus, P., Maffulli, N., Bonar, S.F. (2002). Time to abandon the
“tendinitis” myth. BMJ 324:626-7
Krischek, O., Hopf, C., Nafe, B., Rompe, J-D., (1999) Shock-wave therapy for tennis and
golfer’s elbow – one year follow-up. Archives of Orthopedic and Trauma Surgery.
Vol 119, Issue 1-2: 62-66
Mackay, D., Rangar, A., Hide, G., Hughes, T., Latimer, J., The objective diagnosis of early tennis
elbow by magnetic resonance imaging. (2003). Occup Med 53(5): 309-12
Magee, D.J. (2008) Orthopedic Physical Assessment. Saunders Elsevier, 5th Ed:850
Martinez-Silvestrini, J.A., Newcomer, K.L., Gay, R.E., Schaefer, M.P., Kortebein, P., Arendt,
K.W. (2005). Chronic lateral epicondylitis: comparative effectiveness of a home exercise
program including stretching alone versus stretching supplemented with eccentric or
concentric strengthening. Journal of Hand Therapy, Vol 18 (4): 411-420
McHardy, J. M., Pollard, H.P. (2005). Golf and upper limb injuries: A summary and review of the
literature. Chiropractic and Osteopathy, 13:7: 1-7. Retrieved from
http://www.biomedcentral.com/content/pdf/1746-1340-13-7.pdf
Nicholas Institute of sports medicine and athletic trauma. Retrieved from
http://www.nismat.org/ptcor/tennis_elbow
Palastanga, N., Field, D., Soames, R. (2006). Anatomy and human movement – structure and
function. 5th Ed. Butterworth, Heinemann, Elsevier. 152-158.
Shiri, R., Viikari-Juntura, E., Varonen, H., Heliovaara, M. (2006). Prevalence and determinants
of lateral and medial epicondylitis: A population study. American Journal of
Epidemiology, Vol 164, Issue 11: 1065-74
Simunovic, Z., Trobonjaca, T., Trobonjaca Z. (1998, June). Treatment of medial and lateral
epicondylitis – tennis and golfer’s elbow – with low level laser therapy: A multicenter,
double blind, placebo-controlled clinical study on 324 patients. Journal of Clinical Laser
Medicine and Surgery. 16 (3): 145-151
Stahl, S., Kaufman, T., (1997). The Journal of Bone and Joint Surgery. 79-A, 11: 1648-52
Wadsworth, T. G. (1987). Tennis Elbow: conservative, surgical and manipulative treatment.
British Medical Journal Vol., 294: 621-3. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245660/pdf/bmjcred00010-0035.pdf.
Waldman, S.D., (2010). Physical diagnosis of pain. 2nd Ed. Elsevier Inc. 130-32
Waugh, E.J., (2005). Lateral epicondylalgia or epicondylitis: what’s in a name? J Orthop Sports
Phys Ther 35(4): 200-212

back hand injury

Figure 1.
Medial Epicondylitis (above)
Lateral Epicondylitis (below)

Centric Exercisse

Figure 3. An over-the-top golf downswing

Figure 3.
An over-the-top golf downswing

(an obvious position to contain internal shoulder
rotation of the right side, for the right-handed golfer)

Figure 4.

Figure 4.

 

An Out-to-In path (connects outer-right quadrant of the ball) An In-to-Out path (connects inner-right quadrant of the ball)

Note the internal rotation of the right shoulder Note the external rotation of the right shoulder which always goes with correct club path and correct club
path and correct club presentation to ball.

Handicap Golfer
Figure 5. A low-handicap golfer at risk for RIGHT MEDIAL EPICONDYLITIS
He has typical Phase II over-the-top right-elbow-straightening compensation –
the right forearm and wrist go into abrupt pronation and flexion, on the frontal plane, from
an internally rotated shoulder

Professional Golfers
Figure 6. Professional golfer Jim Furyk at risk for RIGHT LATERAL EPICONDYLITIS
He has typical Phase II over-the-top right-elbow-straightening compensation –
the right elbow must be forcefully extended, and the right wrist forcefully straightened from an
eccentric extension, both on the frontal plane, while the shoulder is being held in internal rotation

Professional golfer

Figure 7. Professional golfer Nancy Lopez at risk for LEFT LATERAL EPICONDYLITIS

He has typical Phase II over-the-top left-elbow-straightening compensation –
there is rapid flexion to extension at the left elbow, with a short lever starting at the elbow
(instead of the shoulder), which is similar to a single-handed tennis backhand movement.
At the same time the right arm, held in internal rotation also extends forcefully, exerting a
greater-still pushing-force on the left forearm.

 

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