Low back pain in golf

Low back pain, golf, swing, overexertion, under-recovery, referred pain, radiating pain, stiffness, sports-related pain, hobby, movement restriction, hypermobility, postural control, force production, kinetic chain

Low back pain is the most common musculoskeletal issue related to golf, affecting up to one in four players. Symptoms rarely stem from tissue damage; instead, the pain and discomfort result from increased load on the lower back. It’s essential to understand that while low back pain or discomfort might occur during or after a round, this doesn’t necessarily reveal the underlying causes. Often, the lower back is mistakenly blamed when, in reality, it compensates for other body parts not functioning effectively.

The lower back becomes overloaded as it compensates for movement restrictions, weaknesses in force production and control or balance issues elsewhere in the body. Repetitive or persistent low back pain often develops over time due to strain and harmful movement patterns. Extended cycles of overexertion and under-recovery can also lead to tissue damage. Therefore, working through pain is usually unwise. It's crucial to identify and address the underlying factors before it's too late. After tissue damage occurs, recovery generally requires a much longer rest period compared to addressing pain caused by overuse alone.

During a golf swing, the spine experiences multidirectional forces, such as compression, shear and rotational forces. These forces are typically intense and the movement is performed at near-maximum speed, which increases the risk of injury and discomfort, especially if the motion is not well-controlled. The compression forces measured in the spine during a swing can be up to eight times body weight. For an average man weighing 85 kg (about 187 lbs), this equates to roughly 680 kg (about 1500 lbs) of force on the spinal structures. Understanding this highlights why the lower back often aches during a round. It’s essential to strive for a swing technique that distributes these forces across a larger area, reducing the strain on the lower back.

Restrictions in the movement of the ankles, hips, thoracic spine or shoulder areas, combined with poor core stability, diminished balance or a poorly functioning kinetic chain, force the lower back to move beyond its limits and bear extra load during the swing. When this pattern repeats from one swing to the next, it predisposes the lower back to pain. Overuse injuries often affect athletes in sports where certain movements are repeatedly performed.

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Structural causes of low back pain

Soft tissue strains and tears: Muscle strains, often referred to as "pulled muscles," occur when muscle fibers are overstretched, leading to them tearing. This typically happens when a muscle contracts forcefully while already in a stretched position. Common symptoms include localized pain and possible swelling around the injury site. Depending on the severity, healing can take anywhere from a few days to several weeks.

Disc injuries and bulges: Lumbar intervertebral discs function as protective shock absorbers and allow movement in the spine. Frequent improper loading can lead to tears in the disc's outer wall and result in bulging. A bulging disc can irritate nerve roots, causing radiating pain into the lower extremities and potentially leading to neurological deficits.

Over time, discs can undergo degenerative changes, resulting in decreased hydration and elasticity. This can reduce spinal mobility and increase load on the vertebrae. While such changes can cause localized irritation, it's important to note that degenerative changes in the discs are often normal age-related occurrences that don't always lead to symptoms. Pain arises when an already compromised area is forced to move in a manner it can no longer handle, leading to overstrain and discomfort.

Facet joint arthritis and spinal stenosis: In facet joint arthritis, the elasticity of cartilage deteriorates, which leads to erosion. Recovery of damaged cartilage becomes impaired, resulting in further cartilage loss. When cartilage wears away, bony surfaces can become damaged and osteophytes may develop, leading to joint expansion and increased stiffness. This affects the joint's movement, necessitating compensatory motion in the spine, which can further lead to pain.

Simultaneously, ligament laxity and muscle atrophy may be observed. This can not only cause localized back pain but also radiating pain due to spinal canal stenosis caused by degeneration.

Stress fractures and vertebral slips: Stress fractures in the spine are relatively common in sports that involve repetitive rotational forces. These fractures occur due to rapid spinal extension and rotation, causing adjacent vertebrae to impact each other at their maximum range of motion.

Children and adolescents are particularly vulnerable, as their bones are softer and more susceptible to changes. In young competitive golfers, stress-related changes in spinal structures are frequently noted, sometimes forcing long breaks from training to allow for recovery. These issues are often preventable through appropriate auxiliary exercises and well-planned training.

Stress fractures and vertebral slips typically cause localized back pain that worsens in situations where increased pressure is applied to the spine.

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Functional causes of low back pain in golf

Achieving a smooth and efficient golf swing requires precise coordination throughout the body, good mobility, core stability and balance. The underlying factors contributing to low back pain can be broadly categorized into biomechanical challenges, which lead to compensatory movements in the lower back and swing technique issues that directly affect load on spinal structures.

Biomechanical challenges may include movement restrictions, altered movement patterns, impaired balance or difficulties in force production, all of which can increase the need for compensatory movements. Common biomechanical issues associated with golf-related lower back pain include:

Lack of hip or thoracic spine rotation:

Preventing low back pain often requires developing movement patterns and eliminate movement restrictions, particularly in the hips and thoracic spine. The rotational movement in a golf swing should predominantly occur in these areas. When stiffness exists in the hips or thoracic spine, compensation often occurs by adding extra rotation in the lumbar spine.

However, the orientation of the facet joints in the lumbar spine does not allow for significant rotation without increasing compressive loads, which raises the risk of injury. Comparing the rotation of the lumbar and thoracic spines reveals that the thoracic spine can rotate approximately 30-40 degrees, while the lumbar spine has only about 10 degrees. Increased rotation in the lumbar facet joints has been linked to damage to the joint surfaces and tears in the outer walls of the intervertebral discs.

In cases of hip mobility restrictions, a similar compensatory pattern emerges, where the lack of hip movement is made up for by increased lumbar rotation. Specifically, a deficiency in hip internal rotation tends to lead to this compensation. During the golf swing of a right-handed player, the right hip moves into internal rotation during the backswing, while the left hip does the same during the follow-through. Restrictions in either hip can therefore necessitate additional lumbar rotation during the swing.

Core activation weakness and balance issues:

A well-activated and strong core is essential for a stable, balanced and powerful golf swing. The golf swing is a complex movement involving coordinated action between the lower and upper body to transfer energy from the ground to the club. A strong core stabilizes the spine and pelvis while minimizing the forces acting on the lumbar spine during the swing.

Not only does a strong core reduce the risk of injury, but it also improves ball striking accuracy, swing consistency and distance. Improving balance further enhances these benefits.

A stable and balanced swing reduces lateral movements during the stroke, thereby minimizing the load on the lower back and enhancing movement repetition. Poor balance, conversely, prevents golfers from effectively controlling their bodies and shifting their weight correctly, leading to swing faults such as excessive lateral movements, early extension or loss of posture during the golf swing. These factors not only increase the risk of injury but also make the swing challenging and difficult to repeat.

Challenges related to swing mechanics

The golf swing can be executed in many different ways and what works for one player may not work for another. The goal is not to have everyone swing the club in the same manner, but rather to consider individual body characteristics and develop a swing technique that suits oneself.

However, in preventing low back pain, it's essential to understand how the mechanics of the golf swing impact the body. Below are some swing mechanics that often lead to low back issues and pain.

Reverse spine angle is one of the most common swing characteristic leading to low back pain. In this scenario, the upper body extends and tilts excessively toward the target during the backswing, increasing the compressive and shear forces on the lower back.

Reverse spine angle often arises from a lack of rotational mobility in the hips and thoracic spine, which is compensated for by excessively bending the lower back. While the goal might be to increase backswing length and thus enhance force on the ball, the result is often simply back pain and reduced repeatability.

Reverse spine angle

Increased lumbar lordosis or "S-posture" is another common issue involving increased lordosis in the lumbar spine, which usually manifests even before the swing begins. This increased curvature places additional pressure and load on the lumbar facet joints, hindering their natural rotational movement. Frequently, the underlying cause of increased lordosis is poorly activated core and weak gluteal muscles, but there can also be misconceptions about needing to maintain an arched lower back during the swing.

Increased lumbar lordosis or S-posture

Hanging back relates to the player's weight remaining on the back foot during the follow-through. This leads to increased lateral bending of the spine away from the target and adds stress to the lower back. This swing characteristic often arises from an attempt to open the clubface at impact, particularly if it is perceived to be too closed. Additionally, past or current lower back pain may cause players to shift their weight backwards as a protective mechanism, further exacerbating the problem.

Hanging back

A player's swing mechanic should always be assessed as part of a clinical evaluation, especially if pain and symptoms are related to golfing. Often, even a simple adjustment in swing technique can yield significant improvements to ongoing symptoms.

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Treatment and prevention of low back pain

Effective treatment and prevention of low back pain requires identifying the underlying causes. This can be achieved through a thorough interview, precise clinical examination and an assessment of sports-specific techniques. It’s crucial to understand how the golf swing and the body work together during the swing.

Depending on the underlying causes of lower back pain, various treatment and prevention methods can be applied. Below are principles used in the treatment and prevention of common causes of golf-related lower back pain.

Improving hip and thoracic spine rotation:

A golf swing requires significant rotational mobility to transfer energy from the body to the club. This movement should primarily occur in joints designed for rotation, namely the hips and thoracic spine; otherwise, the risk of injury increases. It’s important to remember that the hips and thoracic spine do not function in isolation; their performance is influenced by the functioning of other areas. For example, abnormalities in ankle movement can lead to impaired hip control, which in turn affects hip function. Therefore, it’s essential to evaluate a person’s movement as a whole rather than just examining the function of a single joint or area.

Addressing movement restrictions and increasing mobility require systematic and progressive training. A training program should include not only mobility exercises but also strengthening exercises, as restrictions are often associated with weaknesses in both force production and control. Mobility exercises can be performed daily, but it is advisable to have at least one rest day after strengthening exercises. The more intense the training, the longer recovery typically takes afterward.

Progressive training often yields good results in improving mobility; however, sometimes the situation may also require passive treatment. Joint and muscle mobilisation techniques can be used to help accelerate improvements in mobility, especially when physical issues underlie the movement restrictions. In such cases, it’s beneficial to consult a physiotherapist specializing in manual therapy.

Improving core stability and activation:

Developing a strong and stable core through targeted exercises enhances a golfer's physical performance and movement consistency, boosting confidence and enjoyment. Core strength refers to the muscles ability to produce force, while core stability denotes their capacity to keep the spine stable under load.

While increasing core strength is beneficial, stabilizing the core is particularly critical for preventing golf-related lower back pain. If core stability is weak, the abdominal-, back- and gluteal muscles cannot effectively protect the lower back during the swing. Therefore, auxiliary training should focus on developing core stability.

In many cases, we encounter situations where a golfer has good core strength but struggles with activation and stability. In such cases, traditional strengthening exercises may not yield progress. It’s then essential to select exercises that improve core activation in conjunction with stabilizing exercises.

By developing core strength and stability, golfers often see improvements in mobility, coordination, balance, clubhead speed and energy transfer from the ground to the club. Enhanced accuracy and movement repetition also lead to reduced shot dispersion and improved shot precision.

Incorporating core training into a golfer’s fitness regimen can significantly enhance their performance on the course. Improved posture, mobility, and coordination aid in injury prevention while increasing performance usually leads to better shot accuracy and distance.

Challenges related to swing mechanics

In preventing low back pain in golfers, it's crucial to understand how a player’s repeated swing can create stress and overexertion in the back. A thorough evaluation of the player’s swing mechanics is essential for understanding the injury mechanism and developing an effective treatment plan. If the swing technique places excessive strain on the back, merely performing auxiliary exercises may not prevent future pain; instead, the focus must shift to modifying the swing.

Above, I've outlined several typical swing faults that can increase the load on the lower back and contribute to golf-related back pain. Below are a few methods to correct these faults.

Reverse spine angle:

One of the easiest ways to encourage a reverse spine angle is to allow the player to set up behind the ball so that the trail hip is higher than the lead hip. This increases lateral movement during the backswing, which often leads to the upper body tilting toward the target. To eliminate this, the player should position themselves so that the lead hip is raised higher than the trail hip. This encourages better rotational movement without excessive lateral sway or upper body tilt.

Lead hip high, lead shoulder low:

As a drill, take your normal setup position and place a club across your chest. Then, gently shift your lead hip toward the target while allowing it to rise slightly. Perform slow and controlled backswings, keeping the lead hip high while ensuring the lead shoulder remains close to the ground as the upper body rotates. The goal is to avoid the upper body rising and tilting toward the target during the backswing.

Targeting rod drill:

For a second exercise, use a targeting rod, an old club shaft or any another stable object. Place the old club shaft or targeting rod on the ground outside your trail foot and take your normal stance. Imagine there’s a table on the other side of the rod that you’re trying to reach for with your upper body without letting your lower body touch the rod. This drill positions the spine correctly and helps you load weight into the trail leg while reducing lateral movement during the backswing.

Increased lumbar lordosis

Maintaining a neutral spine posture during the backswing is crucial, as it reduces the load on the small joints between the vertebrae in the lower back. However, many golfers face challenges with increased lumbar lordosis, which can occur either at setup, during the mid-backswing or at the top of the swing. This leads to excessive strain on the lower back and increases the risk of injury.

Belt buckle to rib cage:

One effective exercise for addressing excessive lumbar lordosis in the swing is the Belt buckle lift exercise. Start in your normal stance and lift your belt buckle as high as you can. After that, lower the buckle down as far as possible and then lift it back up, pausing at the midpoint. This position should be close to a neutral spine, allowing you to practice the backswing without any movement of the buckle up or down.

Bar behind back:

Another useful exercise involves placing a targeting rod or club shaft behind your back, ensuring it touches your sacrum, shoulder blades and the back of your head. Then, tilt your pelvis backward, causing your lumbar spine to round against the shaft. Next, bend forward from the body while maintaining this rounded back to achieve a typical setup position. This exercise is particularly beneficial if excessive lumbar lordosis is present even in the setup position.

Hanging back:

Remaining on the back leg during the swing increases the load on the lower back and weakens the compressive force on the ball, resulting in reduced ball speed and distance. If you notice that your weight stays excessively on the back leg during the swing, you can try the following exercises to correct this.

Walking through the swing:

Take your normal setup position, perform a backswing and hit the ball. Continue the motion by walking through the swing, shifting your back leg toward the target after making contact with the ball. This will help shift your weight to the lead leg and eliminate staying on the back leg. Practice this first without a ball, then with a ball and finally try to achieve a similar weight shift sensation without actually moving the back leg toward the target.

Pushing the club forward:

Take an extra club and place it on the ground with the clubface pointing toward the target. Stand behind the club and rest the clubface of your held club against the end of the grip of the club on the ground. Push the club on the ground forward as far as you can. You’ll notice that you need to shift your weight to the lead leg, which helps prevent staying on the back leg. Aim to achieve the same feeling during your swing.

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Summary

The causes of golf-related low back pain are often varied and can stem from multiple factors. It's important to examine all potential underlying issues, such as biomechanical challenges, swing techniques and movement patterns of the body. In particular, limitations in the mobility of the hips and thoracic spine, weakened core stability or balance issues can place additional strain on the lower back. Technical swing challenges, such as improper movement patterns, can also transfer stress to the lumbar structures, contributing to the development of back pain.

Prevention is often easier than managing existing pain. Maintaining good mobility and strength, along with a balanced swing technique, can significantly reduce the risk of injury. It’s important to remember that the low back does not operate in isolation; it is part of the entire body’s kinetic chain. Issues in other areas can create stress peaks in the back, leading to pain.

Customized exercise programs and swing technique adjustments not only reduce the risk of injury but also enhance the efficiency and repeatability of the swing, often resulting in noticeable improvements on the course. This makes the game more enjoyable and pain-free, allowing for full concentration on skill development.