E-edition: #GolfMedicine

Dear Reader, Welcome to this special BJSM e-Edition on #GolfMedicine. Over the last few decades golf medicine has progressed to support professional golfers’ physical and mental health as well as promoting physical activity to the general population. Golf is a fantastic sport that can be played at any age and the handicapping system allows players of mixed abilities to play, compete and socialise together. Like many sports golf faced some big challenges during the COVID-19 pandemic. However, with a series of risk reduction measures and the recognition of its significant health benefits both amateur and professional golf were able to resume safely. This edition is supported by The R&A, who together with the USGA govern the sport of golf worldwide. It is also supported by the European Tour, the Ladies European Tour,  EDGA, and the International Golf Federation

We are massively grateful to all of the collaborators on this project. A huge thank you to Dr Roger Hawkes (President of BASEM), Dr Andrew Murray (Chief Medical Officer for the European Tour), and Dr Steffan Griffin (BJSM Deputy Editor) for supporting this project as well as Dr Danny Glover and Jimmy Walsh for creating and producing many of the infographics and podcasts included. This e-edition aims to offer the reader an insight into golf medicine, including changes due to COVID-19, the performance aspects of golf and its health benefits, as well as considering the medical issues and injuries linked to the sport. We hope to give you an overview of the important things to consider for any healthcare professional working with golfers and provide resources so you can find out more. Sincerely, Dr William Wynter Bee | @WillWb123 & Dr Sean Carmody | @seancarmody1

Dr Andrew Murray works as Chief Medical Officer for the Tour, and as a consultant in Sport and Exercise Medicine (SEM) at the University of Edinburgh. “Golf is played by over 60 million persons worldwide, by persons from 4 to 104. Golf can provide health enhancing physical activity and a range of health benefits (see Golf and Health), while injury prevention and skin cancer prevention are of high importance.

"The difference between winning a four-round tournament and not winning is, in the vast majority of cases less than 1%. Whether you are aiming to win Majors, or take a shot off your score, this edition can help with input from physio, sports psychology, physical preparation, medical and nutrition experts.”

Padraig Harrington, a three-time Major winner and the 2020/2021 Ryder Cup Captain, has provided us with a great player’s perspective. In this BJSM podcast, he discusses some of the challenges faced by professional golfers and discusses how the current COVID-19 pandemic has impacted the game.

Dr Andrew Murray has been at the centre of the return of professional golf during the COVID-19 pandemic and this video explains how the Tour has adapted:

During COVID-19, many tools have been used to help tournaments return safely. The article below explains how sports leaders and the UK government developed the five-stage model for elite sport on how to get sports back up and running safely.

• Sports medicine leaders working with government and public health to plan a ‘return-to-sport’ during the COVID-19 pandemic: the UK’s collaborative five-stage model for elite sport

The World Health Organization (WHO) developed a risk assessment tool and the article below explains how this can be implemented to recommence professional sport safely during the COVID-19 pandemic.

• When can Professional Sport Recommence Safely during COVID? Risk Assessment

Dr Dionisio Izquierdo and Dr Jane Simpson are two Sport and Exercises Medicine Registrars who attended the UK Championship at The Belfry. They explain in their blog what it is like to attend a golf event as a medic and how the new COVID-19 risk reduction strategies were implemented at the event.

• The PGA European Tour: Teeing off during COVID-19

The Ladies’ European Tour was able to return safely at the Aberdeen Standard Investments Ladies Scottish Open at The Renaissance Club followed by the AIG Women’s Open at Royal Troon. Three-time LET winner Beth Allen takes us through the practical process of screening for COVID-19 on Tour:

It is also critical golfers return safely through a Graduated Return to Play Procedure (GRTP) post COVID-19, as demonstrated in the infographic and article below.

• Recommendations for return to sport during the SARS-CoV-2 pandemic

Restarting golf at the grass roots level has been recognised as important to take advantage of its significant health and social benefits. The R&A and PGA (Professional Golfers Association) provide excellent advice, guidance and videos on the safe re-opening of golf at club level in the UK.

As in all sports, golf performance is developing fast and is key to success in professional golf as well as benefiting golfers at all levels. This infographic provides a summary of some of the common areas professional golfers focus on to maximise performance. These include strength and conditioning (S&C), sports psychology, nutrition, sleep and managing travel and training schedules. The European Tour Performance Institute (ETPI) has helped provide players with these services and is a great resource for players, performance coaches and healthcare professionals.

A recent BJSM blog (Beyond physical load in golf – the tip of the load iceberg) provides an insight into load monitoring in golf and how golfers could use this to improve performance and prevent burnout and injury. They consider the different types of load and summarise them in the image below “The iceberg of golfing load”.

There has been a huge shift in golfers’ physical preparation over the last 10 to 20 years with many more golfers at the top of the game, such as Tiger Woods, Lexi Thompson, Rory Mcllroy, and Brooks Koepka, focusing on Strength and Conditioning (S&C) to improve performance. COVID-19 stopped many sporting events and provided some with a unique opportunity to focus on S&C. Bryson DeChambeau took full advantage of this, putting on large amounts of muscle and is the latest golfer to demonstrate the benefits of S&C, winning his first Major, the US Open at Winged Foot, soon after lockdown ended. In this podcast, Dan Coughlan (S&C Coach - European Tour) explains the shift in S&C in golf and how the different S&C programmes used by tour players can improve performance while minimising injury risk. He also discusses the S&C set up on the European Tour.

A recent blog by a Nigel Tilley (Physiotherapist - European Tour) and Simon Brearley – (S&C Coach - European Tour) further describes the importance of S&C to develop power and increase driving distance. They consider how to do this in a safe way and point out the clear correlation between driving distance and how much professional golfers earn.

• How the best golfers in the world are using S+C to elevate their performance

Below we have also included some other key articles linked to S&C in golf.

• Strength and Conditioning in Golf: Probability of Performance Impact
• The effects of strength and conditioning interventions on golf performance: A systematic review

To optimise performance, getting nutrition right is key as well as efficient travel planning, as professional golfers will spend a lot of time crossing time zones around the world to compete in different golf tournaments. In this podcast the performance nutritionist David Dunne discusses the practical considerations for the travelling athlete, including strategies the practitioner can employ to help reduce the risk of illness, minimise the effects of jet lag, improve sleep and optimise performance. David has also written a blog providing advice on nutrition for golfers pre-round, during the round, recovering from the round and during travel.

• Nutrition for golf with David Dunne

Sports psychology has become a huge aspect of performance in golf and famous psychologists such as Bob Rotella and Tom Young are cited by players as having a huge impact on their games. Tom Young, who worked with the victorious European 2018 Ryder Cup team at Le Golf National, has developed a fantastic BJSM blog summarising some useful sports psychology interventions such as creating vivid pictures, managing critical moments and purposeful practice.

The Golf and Health Project, supported by The R&A and the World Golf Foundation and its partners, has produced and published high quality science that evidences golf’s physical and mental health benefits to provide information to existing golfers, non-golfers, golf bodies and policy makers. Dr Roger Hawkes, executive director of the project explains in this video with the help of professional golfers, researchers and policy makers the significant public health benefits of golf.

Dr Andrew Murray’s PhD focused on golf and health, providing us with much of the original research as demonstrated in the scoping review article below which is summarised in the infographic, and explained further in this video and BJSM podcast.

• The relationships between golf and health: a scoping review

In 2018, an international consensus statement on Golf and Health was published in the BJSM to help guide action by people, policymakers and the golf industry to realise the health benefits of golf while minimising injury. It is discussed in more detail in this BJSM with Dr Andrew Murray.

• 2018 International Consensus Statement on Golf and Health to guide action by people, policymakers and the golf industry

Furthermore, a recent international study by Professor Maria Stokes, OBE (University of Southampton) and Dr George Salem (University of Southern California) backed by The R&A has found golf can improve muscle strength and balance amongst older participants.

• Strength and Balance Benefits in Golf

The R&A published The R&A Golf and Health Report (2016-2020) which provides a detailed and comprehensive overview of the health enhancing benefits of golf. It summarises the scientific research and details case studies considering the impact of the golf and health movement. It also highlights future opportunities, including the possibility of golf on prescription. Vivien Hamilton’s story from The R&A is just one example of how golf can aid recovery after serious illness. One project which has taken these health benefits to heart is Golf In Society. This is a group that arranges golf for older adults with health conditions including dementia, Parkinson’s disease and depression to improve health in later life.

Disability golf has become much more popular over the last 10 years and EDGA hosts multiple successful disability golf tournaments and promotes the health benefits of golf for people with disability. This video from EDGA tells the stories of a few of the athletes in disability golf.

This BJSM blog by Tony Bennett (President of EDGA) discusses why golf is a great sport for people living with disabilities and the real health and social benefits it can bring. Golf – therapy, recreation, competition and passion The R&A case studies also have countless stories of how golf has helped people living with disabilities through challenging times. The R&A has also produced The Modified Rules of Golf for Players with Disabilities. The Modified Rules of Golf for Players with Disabilities Disabled golfers may be at risk of certain medical conditions which are important to understand. Furthermore, for some during travel specific considerations such as risk of dehydration may need to be considered. The documents below provide excellent advice on these issues.

• Practical management: common medical problems in disabled athletes
• Handbook of Sports Medicine and Science: The Paralympic Athlete

Looking after golfers, like many elite sports people, involves not only managing musculoskeletal injuries but also a lot of general medical practice. The European Tour medical team has developed specialist services embedded within the tour, including skin cancer screening, antidoping services and specialist MSK provision with SEM doctors, physiotherapists, S&C coaches, radiologists and orthopaedic surgeons. Mental health promotion and training has been a recent focus with involvement from specialist sports psychiatrists and psychologists. Below we have provided information key to clinicians involved in providing medical care in golf.

Many golfers and other people working within golf are exposed to the sun for prolonged periods and are at greater risk of skin damage and potential cancers making practical skin protection advice sensible. The video below lays out some of the key things to consider. Dr Allan Matthews and Dr Susannah Fraser are two European Tour dermatologists. They provide skin screening for European Tour players, caddies and staff and have kindly provided us with a great blog about dermatology in golf. - Being safe in the sun – The European Tour perspective

In recent years there has been a big focus on mental health in elite sport, with the recent International Olympic Committee (IOC) consensus statement providing some recommendations to help identify athletes at risk of mental health conditions and advice on management.

• Mental health in elite athletes: IOC Committee consensus statement (2019)

The IOC also recently produced the Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1) to aid in the assessment and recognition of mental health disorders in elite athletes.

• International Olympic Committee (IOC) Sport and Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Recognition Tool (SMHRT-1): Towards better support of athletes’ mental health.
• Download full Sports Mental Health Assessment Tool (SMHAT)
• Download full Sports Mental Health Recognition Tool (SMHRT)

In golf specifically, there is high stress with lots of travel and individual pressure put on players. In recent years many high-profile players, such as Thomas Bjorn, have spoken about the mental strain that can be experienced when competing at an elite level. This article helps identify some of the strains touring professionals often experience which highlights the importance of discussing mental wellbeing and screening for mental health issues.

• Life in the travelling circus: A Study of Loneliness, Work Stress, and Money Issues in Touring Professional Golf

The European Tour has put in place mental health training for its staff and created resources such as this infographic to promote good mental health.

Dr Phil Hopley, consultant psychiatrist, was instrumental in establishing the mental wellbeing programme in golf and he discusses this and how to manage mental health conditions in golfers in this podcast.

Antidoping

As with many elite sports, an understanding of anti-doping is critical and the podcast below with Michele Verroken (Anti-doping advisor to the European Tour) outlines the three essential things every clinician should know in relation to anti-doping in golf.

As with all sports the key to accurate and reliable epidemiological studies hinges on consistency in methods and definitions used in studies. In 2020 the IOC called for sport specific guidelines for this purpose and the recent golf consensus statement for recording injuries and illness in golf is included below.

Golf puts specific strain on different areas of the body and common injuries are those associated with overuse from the repetitive movements required.  This systematic review highlights the commonest golf injuries to be to the lumbar spine region followed by the hand and wrist. The key findings are summarised in this video and the infographic below.

• Systematic review of musculoskeletal injuries in professional golfers

We have also included several other key articles which provide an overview of common golf injuries, linking them to biomechanics and considering their management.

• Getting to grips with golf injuries
• Golf injuries

This podcast with Dr Roger Hawkes expands on many of the themes already considered but also provides a great overview of the MSK injuries seen in golfers.

The back appears the most at risk region of the body and below are some of the key papers considering the risk factors and management of back injuries.

Upper limb injuries are common in golf with the most common injury area being the lead wrist, it is therefore critical to be able to undertake a thorough hand and wrist assessment to identify specific pathology. Mr Doug Campbell provides a great assessment of how to undertake a hand and wrist examination:

We have included some of the key papers that consider the common wrist injuries in golf and provide an explanation of the common underlying pathologies and management options.

The shoulder is another key area to understand in golf and the following papers suggest the lead shoulder to be at greater risk of injury and consider the underlying pathologies.

Although they appear less common, lower limb injuries do still occur in golf. The study below considers the difference in hip morphology in elite golfers and suggests the prevalence of cam morphology and labral tears to be greater in the trail hip.

• Hip morphology in elite golfers: asymmetry between lead and trail hips

The knee also appears to be an at risk area. The systematic review below considers the prevalence and the biomechanics of knee injuries in golf.

• Risk factors for knee injury in golf: a systematic review

Golf is a sport that often, even after major surgery, you can still play. The paper below suggests most golfers are able to get back playing golf after a joint replacement and several professional golfers have had success on tour after joint replacement. One example is Fred Funk who went on to win the U.S. Senior Open after a total knee replacement in 2009.

• Return to Golfing Activity After Joint Replacement

It has been great to see both professional golfers and the general public out playing golf again and we hope this article offers some information on getting tournaments and athletes back safely during and after COVID-19. It also provides information on how golfers can optimise their performance, as well as the significant health benefits people of all ages and abilities can gain from the sport.

Please do share this e-edition, and the content within it widely, and think about making your contribution to golf research.