GOLFERS, STRENGTH TRAINING & INJURY PREVENTION: WHAT THE RESEARCH SAYS
Whether or not the increased training loads of elite golfers are causing injury is a hotly debated topic at the moment. The argument usually goes something like this: [Insert name of recently injured tour pro here] trains in the gym and lifts weights and that same player got injured so training and lifting weights causes golfers to get injured.
At first glance it seems logical and is pretty persuasive considering the names cited are often some of the most high profile players in the world.
However as with most things in life the situation is a lot more nuanced and when you start to look at cold hard empirical data these claims don’t stack up to well.
A Case Study Of One Doesn’t Make Evidence…
As I said these arguments are often made citing one player - typically the one who has most recently been out injured. However, what is usually missing from this argument is the mention of the many top players who train regularly and don’t get injured - Phil Mickelson, Justin Rose, Paul Casey, Henrik Stenson, Justin Thomas, Jordan Spieth, Hideki Matsuyama, Rickie Fowler, Matt Fitzpatrick, Danny Willet, Rafa Cabrera Bello, Tony Finau, Alex Noren, the list goes on and on.
Further, a lot of scientific research has been carried out in the area of injuries in golf, sports in general, weightlifting and physical training, and this research is held to a much higher standard of statistical significance than the case study of one individual. Experiments are carried out with large randomised sample sizes, utilising control groups and measures of reliability and validity.
So What Does The Research Say?
In 2014 a huge meta-study (10) found that strength training reduced sports injuries to less than 1/3 and overuse injuries could almost be halved! Interestingly, this study also found that stretching had no relationship to injury prevention.
This is because strength training results in a number of changes beyond muscular adaptations, including positive changes/ increased strength of connective tissue (1) and increases bone mineral density (16).
When we look at the research on injuries as a result of weight training itself we see a similar story too. Studies indicate that injuries are relatively low for weight training, and it is largely considered less risky than many forms of sport, this is true even for those who push weight-training to extreme intensities. Additionally, injury risk can be kept at a minimal level with proper programming (i.e. correct load and volume) and instruction of technique (7).
Much of the literature relating to injuries in golf reports the most common injuries are due to overuse (12). Indeed one study interviewing over 700 golfers of a wide range of skill and age, both male and female, found that of the 637 injuries reported, a massive 86.2% were overuse. 92.3% of back injuries were overuse-related, 92.0% to the shoulder, 95.7% to the knee, and 98.6% to the elbow (6).
Now all of the studies pertaining to injuries in golfers have relied upon golfers self-reporting their injuries, which has obvious issue in terms reliability of both the categorisation and number of injuries (what is an “injury” to one may just be a “minor bother” to another depending, for example, on pain threshold), and other studies have reported lower numbers for overuse injury. But regardless of the exact numbers, however, it is largely agreed upon that overuse is the most common cause of golf-related injuries.
Let’s pause for a second and reflect - potentially 80% of all injuries in golf are overuse and appropriate strength training could halve the of incidence overuse injuries!
A slight extension of the argument presented earlier is that golfers training more intensely, or with greater loads than has perhaps previously been the norm, is causing higher injury rates.
However, once again scientific research has actually come to the opposite conclusion - high workloads may be protective against injury and under training may even increase the risk of injury. Pertinently the same study also found non-contact injuries were caused not by training itself but by inappropriate training programs (5).
Correlation Doesn’t Mean Causation
One of the golden rules of statistics is that correlation does not equal causation. Just because the movements of two variables track each other closely over time doesn't mean that one causes the other. For example, as you can see from the image below, the more margarine you eat the more likely you are to get divorced!
If we take it that injury rates amongst golfers are indeed increasing and it is evident that strength training/ working out is becoming more popular with elite players, there is certainly a correlation. However, as we’ve just discussed, research clearly demonstrates that strength training reduces the risk of injury.
So either it is simply a coincidence or there are other factors at play here.
The ‘Modern’ Golf Swing
The modern golf swing involves a large shoulder turn while restricting hip rotation with the idea that a quiet lower body will increase consistency, while having a large hip-shoulder angle (X-factor) yields a large Stretch Shortening Cycle for greater rotational velocity.
However, this large dynamic x-factor has been linked with golfers reporting lower back pain, particularly if the range of motion is beyond the amount they display passively (11). Further research has hypothesised that this could be due to a lack of muscular or neuromuscular control of high velocity rotation, and may be putting strain on their spine by exceeding their normal flexibility when rotating quickly (4). This is supported by findings that the more rotational velocity increases, the more muscle force may be absorbed into the connective tissue. This allows for more rotation but could put the connective tissues at risk (9).
In comparison, the classic golf swing minimises X-factor by lifting the front heel during the backswing, decreasing the X-factor angle. This likely reduces speed, but also likely reduces torque through the lumbar spine. The classic swing also reduces the lateral bending (Reverse C) by being more upright, which could ease the stress on the trail side of the lower back during swings (4).
In short, over time repeated rapid rotations could affect the stabilising structures and result in injury/pain. This isn’t a huge surprise when you consider the golf swing exposes the player to peak compressive forces up to 8x bodyweight through the lumbar spine (8). This is about as high as the force an American Football offensive line is exposed to while performing a block (3).
The high forces involved in the golf swing become even more of an issue when you consider golf is a skill game and requires LOTS of practice and repetition to get good at.
Non-existent Off-season & Early Specialisation
The same study we looked at earlier regarding injuries in golf also found the number of injuries to the back and shoulder increased as time spent playing/practicing increased, and that those who played at least 4 rounds per week or hit more than 200 balls per week had significantly higher instances of injury (6).
Similarly, other studies suggests the significant factors that influence injury risk are time spent practicing and time spent playing, and that higher instances of overuse injury are seen in athletes that specialise in one sport early or spend more than 9 months per year on their sport (2,13).
Managing the volume of golf swings is therefore likely a large part of the puzzle of preventing injury to golfers.
This obviously presents an issue in modern elite golf where golfers play year round in tournaments across the world - unbelievably the European Tour season officially ends in mid November and starts again early December! This is compounded double when you think things like the FedEx Cup, Race to Dubai or the Ryder Cup that extend the season often only involve the best players - the ones who typically have some of the highest swing speeds - so these players are exerting an even greater physical toll on their bodies.
If you are lucky enough to be able to play year round, it is probably pertinent to periodise your golf practice and program in ‘rest’ periods of reduced volume in order to restore and regenerate the body from the asymmetrical pattern that is the golf swing.
And perhaps most importantly, youngsters should not jump straight into the hours and hours of daily practice required to reach the elite level - instead build gradually; playing multiple sports across a week to build an athletic foundation and movement context. As they age they can become more specialised and can steadily increase this volume year upon year, thereby building higher and higher tolerance to the volumes required.
It should also be noted that excessive rapid increases in training loads are likely responsible for a large proportion of non-contact soft tissue injuries (5). As such, if you have an off-season break where you can’t play, perhaps it is better to steadily increase the volume of swings rather than jump straight into a full playing schedule from a standing start (or at least gradually increase the number of rotational movements done in the gym setting prior to season start). Similarly, school age athletes may be advised to avoid rapidly increasing practice time and volume of swings during the school holidays.
Tl;Dr
We have flip-flopped the facts - golfers who play more than any of their previous counterparts and swing at incredibly fast speeds are turning to strength training to help them prevent injuries and overcome issues they already have (anecdotally there is an increasing number of young tour pros, and college players, turning up with historical back issues). There will therefore always be a proportion of golfers who train and wind up injured not due to their training, but in spite of their training.
Appropriate strength training is in fact a useful dare I say, essential part of the modern tour professionals toolbox, allowing their bodies to survive the huge loads of the modern golf swing and large number of repetitions required in order to maintain year round performance. Rory McIlroy probably put it best when he said “The whole reason I started this is because I was injured. I'm trying to make my back as strong as I possibly can so that when I come out here and swing a golf club at 120 mph and I'm robust enough to take that 200 times a day.”
Or maybe Jason Day, who when asked about the reasoning behind his focus on fitness, replied with typical Australian succinctness - “I was sick and tired of getting injured all the time.”
References
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