There are many research articles surrounding low back pain and the golfer. Many studies suggest many causes and theories as to what can be causing the low back pain many golfers suffer from. In this article I want to draw attention to research that suggests a more rare or lesser known cause of your golfer’s low back pain. Spinal ligaments. It may be why your game and you continue to suffer despite many treatments, many remedies, and a lot of reduced time on the course.
Is it always the golf swing? Higher average club head speed and low back pain
Let’s start with a July 2021 study in the publication Sports biomechanics (x). The focus of this study is on the Minimalist Golf Swing. As an avid golfer, playing through pain you are probably aware of this technique.
In this study the authors examined the Minimalist Golf Swing, as it has been suggested that this swing may reduce lumbar spine, lead hip, and lead knee pain. How? By reducing the ranges of motion and “peak net joint moments”, while positively affecting swing performance, compared to golfers’ existing swings.
To test the theory, the existing and Minimalist Golf Swings of 15 golfers with handicaps ranging from +2 to -20 were compared. During Minimalist Golf Swing downswing, golfers had 18.3% less lumbar spine transverse plane range of motion and 41.8% less lead hip sagittal and frontal plane range of motion, and 39.2% less lead knee sagittal plane range of motion. MGS reduced lead hip extensor, abductor, and internal rotator moments by 17.8, 19.7 and 43%, while lead knee extensor, abductor, adductor and external rotator moments were reduced by 24.1, 26.6, 37 and 68.8% respectively. With MGS, club approach was 2° shallower, path 4° more in-to-out and speed 2 m/s slower. MGS reduced certain joint range of motion and moments that are linked to injury risk factors, while influencing club impact factors with varying effect. Most golf injuries are from overuse, so reduced loads per cycle with MGS may extend the healthy life of joints, and permit golfers to play injury-free for more years.
The most researched and the most discussed cause of low back pain is usually the golf swing. A 2020 study came out of the University of Chicago (1) which hypothesized that professional golfers who achieved a higher average club head speed had more lower back injuries. The theory was tested on male professional golfers who suffered lower back injuries while playing golf. The injured group was composed of 14 Professional Golfers’ Association (PGA) golfers who withdrew from a PGA tour event due to a back injury during the years 2017-2019.
What the researchers found what that age, height, weight or Body Mass Index did not play significant factors in causing low back pain alone. The injured group had a higher mean club head speed than a control group of golfers who had no lower back pain. This study concluded then that: “average club head speed was significantly higher in PGA golfers who suffered back injuries while golfing.” It was the swing.
But what would cause it to be the swing? In some people, the energy needed to strike the ball at a high head speed would come not only from core muscles but core ligaments. Ligaments are often an overlooked factor for pain during a golf swing.
Sacral stress fractures do happen in golfers. It is often misdiagnosed as low back pain. It maybe the spinal and pelvic ligaments and the SI Joint
A November 2020 case report in the journal The Physician and sportsmedicine (2) looked at a case of sacral stress fracture in a female amateur golfer.
From the study: “Sacral stress fractures are rare injuries among professional and amateur athletes and are considered to be an uncommon source of low back pain. These type of fractures are mainly seen in competitive, high-impact sports, most commonly in long-distance runners. Sacral stress fractures are usually overlooked in young patients presenting with low back pain without any trauma history. Diagnosis of sacral stress fractures is often (missed initially) because the history and physical examination of these patients are not specific and conventional radiographic images are frequently inadequate. (The authors) report the case of a woman amateur golf player with a sacral stress fracture who complained of aggravating low back pain. To the best of our knowledge, this appears to be the first report of a sacral stress fracture in a golf player and also the first case of this pathology in low-impact sports. Therefore, physicians should keep in mind that stress fractures can also be seen in low-impact sports.”
We see many patients who have low back pain caused by instability in the lumbar, hip and pelvic regions. These injuries, like the sacral stress fracture can be overlooked because, as in the case history above, doctors may have been looking at MRIs that could not disclose what the problem was.
A February 2020 (3) study described problems that could lead to stress fractures in the sacrum of a female golfer.
Sacroiliac (SI) joint pain radiates into the low back and buttocks area. The SI joint connects the sacrum to the pelvis (ilium). The SIJ transfers large bending moments and compression loads to lower extremities. However, the joint does not have as much stability of its own against the shear loads but resists shear due the tight wedging of the sacrum between hip bones on either side and the band of ligaments spanning the sacrum and the hip bones.
The sacrum of the female pelvis is wider, more uneven, less curved, and more backward tilted, compared to the male sacrum. Moreover, women exhibit higher mobility, stresses/loads, and pelvis ligament strains compared to male SIJs. Sacroiliac pain can be due to, but not limited to, hypo- or hypermobility, extraneous compression or shearing forces, micro- or macro-fractures, soft tissue injury, inflammation, pregnancy, adjacent segment disease, leg length discrepancy, and prior lumbar fusion. In the research above it can also be caused by golf.
The problem here is a problem with loose or lax spinal and pelvic ligaments. Instability can cause hyper-motion in the SI joint and pelvis and cause stress fractures among other painful problems. Please see my article: Stem Cell Therapy and PRP for sacroiliac joint dysfunction
In this case history above golf is called a low impact sport. A February 2021 study (4) disagrees and suggests golf be considered a contact sport because of the damage it can do to a spine.
Rehabilitation after lumbar surgery is challenging in golfers with a high impact swing
In this study, the authors suggest that the force and velocity of the swing can cause the same spinal damage as high-contact sports.
“With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.”
Contact sports create low back pain from obviously impact. Impact injuries lead to a weakening or fraying of the spinal ligaments.
Back pain may be a disc problem. Back pain may be a spinal ligament problem.
For many people it is always an assumption that low back pain and low back pain when playing golf is a disc problem. So when is it a disc problem that needs surgery and when is it a spinal ligament weakness problem that does not need surgery? Doctors at the Mayo Clinic (5) have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.
- First, that pain could be coming from the discs.
- Second that pain could be coming from the spinal ligaments.
Our treatment options
In our practice, Stem Cell Therapy is a treatment for musculoskeletal disorders. We treat degenerative joint disease, degenerative disc disease of the spine, and tendon and ligament injury. We offer stem cells drawn from patient’s own bone marrow. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair — for our purposes, collagen, bone, and cartilage.
We are proud to have authored numerous research papers and forthcoming research papers on the use of stem cells in regenerative healing.
In our own published peer-review research appearing in the July 2018 in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (6) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.
- An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (7)
- Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for LBP (8). This could be due to the over-reliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments. When these ligaments are damaged or weakened, they serve as generators of low back pain. Possibly sciatic like symptoms.
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
Research has shown (9) PRP to be effective in treating degenerative disc disease (DDD) by addressing the problems of spinal ligament instability and by stimulating the regeneration of the discs indirectly (although discs were not directly injected, they showed an increase in disc height).
Although I don’t typically consider DDD to be a major player in neck or back pain, I do treat these areas daily. From my exam, it is typically not the discs that are the issue, but the ligaments at their connection to bone that cause the pain. This is called an enthesopathy. Typically, it is something that will respond well to PRP treatments.
Do you have questions? Ask Dr. Darrow
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Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician.
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1 Baker HP, Mosenthal W, Qin C, Volchenko E, Athiviraham A. Is average club head speed a risk factor for lower back injuries in professional golfers? A retrospective case control study. The Physician and Sportsmedicine. 2020 Sep 18:1-5.
2 Kavukcu E, Akdeniz M. Sacral stress fracture in an amateur golf player: a case report and literature review. The Physician and Sportsmedicine. 2020 Oct 1;48(4):480-4.
3 Kiapour A, Joukar A, Elgafy H, Erbulut DU, Agarwal AK, Goel VK. Biomechanics of the sacroiliac joint: anatomy, function, biomechanics, sexual dimorphism, and causes of pain. International journal of spine surgery. 2020 Feb 1;14(s1):S3-13.
4 Haddas R, Pipkin W, Hellman D, Voronov L, Kwon YH, Guyer R. Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery. Global Spine J. 2021 Feb 5:2192568220983291. doi: 10.1177/2192568220983291. Epub ahead of print. PMID: 33541112.
5 Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2015 Sep 24:1-10.
5 Marc Darrow, Brent Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7(2)-018. BJSTR. MS.ID.001461. DOI: 10.26717/ BJSTR.2018.07.001461.
6 Sanapati J, Manchikanti L, Atluri S, et al. Do Regenerative Medicine Therapies Provide Long-Term Relief in Chronic Low Back Pain: A Systematic Review and Metaanalysis. Pain Physician. 2018;21(6):515‐540.
7 An HS, Jenis LG, Vaccaro AR (1999) Adult spine trauma. In Beaty JH (Eds.). Orthopaedic Knowledge Update 6. Rosemont, IL: American Academy of Orthopedic Surgeons pp. 653-671
8 Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. Spine J. 2013 Jun 5. pii: S1529-9430(13)00402-6. doi: 10.1016/j.spinee.2013.03.050.
9 Gullung GB, Woodall JW, Tucci MA, James J, Black DA, McGuire RA. Platelet-rich plasma effects on degenerative disc disease: analysis of histology and imaging in an animal model. Evidence-based spine-care journal. 2011 Nov;2(4):13.