Original research

Predictors of low back pain in young elite golfers: A preliminary study

Kerrie Evansa,b, Kathryn M. Refshaugea,*, Roger Adamsa, Loretta Aliprandic

aFaculty of Health Sciences, School of Physiotherapy, The University of Sydney, P.O. Box 170, Lidcombe, NSW 1825, AustraliabSchool of Physiotherapy and Exercise Science, Griffith University, Gold Coast Campus PMB 50, Gold Coast Mail Centre, Qld 4726, Australia

cSt Vincent’s Hospital, Sydney, NSW, Australia

Received 27 September 2004; revised 12 May 2005; accepted 20 May 2005

Abstract

Objectives: Low back pain (LBP) is a common and disabling problem amongst golfers. Despite this, the risk factors for LBP in golfers have

not been clearly established and therefore, optimal prevention strategies are not developed. This study was designed as a preliminary

investigation of predictors for LBP in trainee professional golfers.

Design: Longitudinal prospective study.

Setting: Golf courses.

Participants: Trainee professional golfers (NZ14).

Main outcome measures: Potential risk factors included anthropometric variables, flexibility, muscle strength, and muscle endurance.

Associations were evaluated between these risk factors and reported episodes of LBP obtained from participants after every trainee match

during one competition season.

Results: Golfers with a body mass index (BMI)!25.7 kg/m2 and those with a right side deficit of O12.5 s on the side bridge endurance test

reported more frequent episodes of moderate–severe LBP. Golfers with reduced hip flexor length more often reported that LBP affected their

golf.

Conclusions: BMI, the side bridge endurance test, and hip flexor length were found to be significantly related to LBP amongst trainee

professional golfers. Having optimal values on these variables may potentially prevent LBP arising from the repetitive biomechanical

demands of the golf swing.

q 2005 Elsevier Ltd. All rights reserved.

Keywords: Low back pain; Golf; Body mass index; Muscular endurance tests

1. Introduction

According to data collected in 2002 by the Australian

Bureau of Statistics, more than 1 million Australians played

golf in the preceding 12 months. Worldwide, a reported 55

million people play golf (Farrally et al., 2003). Although

considered a relatively benign sport, low back pain (LBP) is

common amongst both amateur and professional golfers,

significantly affecting playing careers (Batt, 1992; Goshe-

ger, Liem, Ludwig, Greshake, & Winkelmann, 2003;

McCarroll, Rettig, & Shelbourne, 1990; Sugaya, Tsuchiya,

1466-853X/$ - see front matter q 2005 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ptsp.2005.05.003

* Corresponding author. Tel.: C61 2 9351 9180, fax: C61 2 9351 9601.

E-mail address: k.refshauge@fhs.usyd.edu.au (K.M. Refshauge).

Moriya, Morgan, & Banks, 1999). For professional golfers,

LBP is the most frequently reported musculoskeletal injury

and is thought to result from the repetitive, asymmetrical

nature of the golf swing and frequent play and practice

(Gosheger et al., 2003; Sugaya et al., 1999). There is limited

prospective research, however, linking specific physical risk

factors and episodes of LBP in golfers. To date, no study has

investigated the occurrence of, or risk factors for, LBP in

trainee golf professionals. These elite golfers might be

thought to be particularly at risk since they are training hard

to become professional tour players, club professionals, or

golf coaches.

Factors that have been suggested to contribute to LBP in

golfers include poor endurance and strength of the trunk

muscles (Grimshaw & Burden, 2000; Horton, Lindsay, &

Macintosh, 2001; Pink, Jobe, Yocum, & Mottram, 1996;

Vad, Bhat, Basrai, Gebeth, Aspergen, & Andrews, 2004;

Physical Therapy in Sport 6 (2005) 122–130

www.elsevier.com/locate/yptsp

Fig. 1. The Biering-Sorensen test of trunk extensor endurance (Biering-Sorensen, 1984).

Fig. 2. Trunk flexor endurance test (McGill et al., 1999).

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 123

Weishaupt, Obermuller, & Hofmann, 2000). However, the

only study examining trunk muscle endurance amongst

golfers (Suter & Lindsay, 2001) focussed on the association

between trunk extensor endurance and quadriceps muscle

function. Whilst this study found that low-handicap golfers

with chronic LBP and poor endurance on the Biering-

Sorensen test had significant inhibition of the knee

extensors, and poor performance on the Biering-Sorensen

test has been shown to predict occurrence of LBP in other

populations (Biering-Sorensen, 1984; Luoto, Heliovaara,

Hurri, & Alaranta, 1995), the relevance of trunk muscle

endurance to risk of LBP in golfers is unknown. The

Biering-Sorensen test (Fig. 1), and both the trunk flexor

endurance (Fig. 2) and the side bridge endurance tests

(Fig. 3) (McGill, Childs, & Liebenson, 1999) all have high

reliability and would be simple to employ in the clinical

examination of a golfer (Latimer, Maher, Refshauge, &

Colaco, 1999; McGill et al., 1999). Given the asymmetrical

nature of the golf swing, the side bridge endurance test,

which is suggested to optimally challenge the quadratus

lumborum and muscles of the anterolateral trunk wall

(McGill et al., 1999), may also detect unilateral differences

in trunk muscle endurance relevant to golfers.

With regard to strength, golfers have been found to have

greater trunk extensor strength than controls (Weishaupt

et al., 2000). Further, various strengthening exercises for the

trunk muscles have been advocated for golfers, in part to

improve performance but also with the aim of reducing the

risk of LBP (Hellstrom, 2002; Pink, Perry, & Jobe, 1993;

Pink et al., 1996). Although studies have reported positive

outcomes for strength training for golfers (Fletcher &

Hartwell, 2004; Grimshaw, Giles, Tong, & Grimmer, 2002;

Hetu, Christie, & Faigenbaum, 1998), these studies did not

examine the risk of LBP.

Golfers are a unique population, employing very specific

movements, some through large ranges of motion, to

achieve positions considered optimal for generating a

consistent, powerful swing. They also sustain positions for

prolonged periods during practice (e.g. sustained lumbar

spine flexion during putting). The repetitive and asymme-

trical motion of the golf swing is thought to result in specific

range of motion deficits (Vad et al., 2004). Although

exercises to improve range of motion are commonly

recommended to golfers, it is yet to be clearly demonstrated

that such exercise programs prevent injury (Sherman &

Finch, 2000).

Although poor conditioning (McCarroll, 1996; Pink

et al., 1996) has been suggested to contribute to LBP in

golfers, the relationship between general fitness and risk of

LBP has likewise not been clearly evaluated. Similarly, the

relationship between body mass index (BMI) and LBP

remains unclear for both non-golfing populations (e.g.

Hellsing & Bryngelsson, 2000; Leboeuf-Yde, Kyvik, &

Bruun, 1999; Mellin, 1987) and golfers (Gosheger et al.,

2003; Theriault & Lachance, 1998). Finally, previous LBP

has been shown to be a risk factor for future LBP in novice

golfers and other athletic populations (Burdorf, van der

Steenhoven, & Tromp-Klaren, 1996; Greene, Cholewicki,

Galloway, Nguyen, & Radebold, 2001). Because no

prospective study has investigated these risk factors in

elite golfers, this preliminary study aimed to determine

whether selected musculoskeletal tests of trunk muscle

endurance and strength, range of motion and anthropometric

variables predicted occurrence and severity of LBP in a

group of trainee professional golfers.

Fig. 3. Side bridge endurance test (McGill et al., 1999).

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130124

2. Methods

2.1. Subjects

Eighteen trainee professional golfers enrolled in the

Queensland (Australia) division of the Professional Golfer’s

Association (PGA) and who lived in the metropolitan region

volunteered to participate in the study. In this 3-year

program, trainees must play at an elite level, attaining an

adjusted handicap average on their best 80% of scores of

C4 strokes or less at the end of their third year.

All subjects were active, male, and aged between 18 and

35 years (Table 1). Sixteen subjects were right handed, 12

were in the first year of the traineeship, 2 in second year and

4 subjects were in the third year of the traineeship. Sixteen

subjects reported having previous episodes of LBP. To

identify subjects at risk from exercise, the Modified

Physical Activity Readiness questionnaire (Kenney, Hum-

phrey, Bryant, & Mahler, 1995) was administered but none

of the subjects were excluded on this basis.

Table 1

Subject’s characteristics. Mean (SD) and range for age, weight, height,

2.2. Testers

All measurements were performed according to a

standard protocol by an experienced manipulative phy-

siotherapist and an exercise scientist, who were blinded to

current or previous LBP status.

upper body mass, upper body length, body mass index (BMI), and Self

Reported Physical Activity Rating (SRPAR)

Variable Mean (SD) Range

Age (years) 23.7 (4.4) 18–35

Weight (kg) 81.0 (13.2) 61–112

Height (cm) 182.7 (7.3) 167.5–193.6

Upper body massa (kg) 34.8 (4.9) 25–45

Upper body lengthb (cm) 79.1 (2.0) 76–83

BMI (kg/m2) 24.2 (3.3) 20–31

SRPARc 4.2 (1.2) 3–6

a Measured using electronic scales (subject prone with anterior superior

iliac spine at edge of plinth).b Measured from anterior superior iliac spine to crown of head.c Self-reported physical activity rating (scored from 1 to 6).

2.3. Protocol

Testing took place 1 week prior to the first trainee

tournament of the year at a local golf course, using

portable equipment. Subjects were then asked to report

occurrence and severity of LBP after each traineeship or

PGA-sanctioned tournament. Since all trainee pro-

fessionals are required to play at least 15 rounds of

golf, with a total of 540 holes to successfully complete

their traineeship year, subjects submitted pain reports on

at least 15 occasions over their 10-month competition

season.

2.4. Variables

Anthropometric measures included height, weight,

BMI, upper body length, and upper body mass

(Table 1). Upper body length was measured from

subject’s anterior superior iliac spine (ASIS) to the

crown of their head. Upper body mass was measured

with subjects in prone lying with their ASIS on the edge

of the plinth so that the upper body was off the bed.

Subjects were instructed to put their palms flat on a set of

electronic scales placed on the floor and the weight of

their body through their hands.

Prior to testing, current level of physical activity was

assessed with the Physical Activity and Health Related

Issues Questionnaire devised by National Heart Foun-

dation (1990, p. 122) and modified by Hunter,

Thompson, and Adams (2000). This questionnaire

comprises a six-point scale, where 1 denotes no

participation in regular exercise, and 6 denotes R5

sessions/week of high intensity exercise of O20 min

duration (Table 1). Strength of the trunk and hip

extensors, trunk endurance and hip and trunk flexibility

were measured. The order of tests was randomised.

Table 2

Questions regarding LBP which were completed by the trainee golf

professionals after each compulsory PGA-sanctioned golf tournament

1. Have you had any low back pain since your last trainee match?

2. What was the average severity of your low back pain since your

last trainee match?

3. Did you have any leg pain associated with your low back pain?

4. Have you had any low back pain whilst playing golf or whilst

practicing since your last trainee match?

5. Has your low back pain affected your golf game at all since your

last trainee match?

6. Has your low back pain stopped you from playing golf or

practicing since your last trainee match?

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 125

2.4.1. Endurance tests

Subjects performed three trunk muscle endurance tests.

Trunk extensor endurance was measured using the Biering-

Sorensen protocol (Fig. 1) as described by Latimer et al.

(1999). Subjects lay prone with their lower body fixed to a

plinth by three seat belts and their upper body resting on a

chair. Subjects were asked to cross their arms over the chest,

lift the upper body and maintain a horizontal position as

long as possible.

The side bridge endurance (Fig. 3) and trunk flexor

endurance (Fig. 2) were conducted and measured as

described by McGill et al. (1999). The starting position

for the side bridge endurance test involved subjects lying on

their side, resting on their forearm, with the elbow joint

flexed to 908. The other arm was positioned across the chest

and legs were extended. Subjects were instructed to lift the

hip off the bed and maintain a straight line with the whole

body (McGill et al., 1999).

For trunk flexor endurance, subjects were positioned on a

plinth with their back resting against a wedge that

maintained 608 flexion from the horizontal. Knees were

flexed to 908 and the feet supported on the plinth, secured

with a seat belt (Fig. 2). In the present study, a universal

goniometer, centred over the greater trochanter and with one

arm placed along the line of the femur and the other placed

on the lateral chest wall, was used to determine whether

subjects deviated from this position. The test was terminated

if subjects were unable to maintain neutral trunk position.

For all endurance tests, subjects were encouraged to hold

their position until fatigue, and were given feedback if they

deviated from the test position. Tests were terminated if

subjects could not maintain the position, if there were any

obvious signs of fatigue or significant increase in pain or

other symptoms. Subjects were rested for at least 10 min

between endurance tests.

2.4.2. Strength tests

Maximum hip and trunk extensor strengths were

measured in the present study. Hip extensor strength was

measured using a hand-held dynamometer (Powertrak) with

subjects in prone lying, a procedure previously shown to

have good reliability (Bohannon, 1986).

Trunk extensor strength was measured with subjects

positioned in long sitting, pulling against a strain gauge

device. The reliability of this test was examined beforehand

and found to be excellent (ICC(2,1)Z0.91). For each

strength test, subjects performed three maximal voluntary

contractions (MVC) and the highest force was recorded.

2.4.3. Flexibility tests

For each flexibility test, subjects were given one practice

attempt, with feedback as necessary. The active knee

extension test as described by Gabbe, Bennell, Wajswelner,

and Finch (2004) was used to measure hamstrings length as

these researchers found this test to have excellent reliability.

Hip flexor length was measured using the modified Thomas

test protocol adopted by Harvey (1998). Subjects were also

asked to perform a standardised sit and reach test (Keogh,

1999).

Lumbar spine flexion and extension range of motion were

measured using the modified–modified Schober method

(Williams, Binkley, Bloch, Goldsmith, & Minuk, 1993).

Trunk side bending range was measured using a motion-

fingertip to floor method (Maher, Latimer, & Refshauge,

2000). In order to measure trunk rotation in standing,

subjects stood on a line with their feet comfortably apart,

equidistant from the centre holding a bar on their shoulders.

They were then instructed to rotate as far as possible to one

side, keeping their knees straight and without moving their

feet. A plumb bob was then dropped, a mark made and

degrees of rotation were measured using a goniometer. The

reliability of this test was examined beforehand and found to

be high with ICC(2,1)Z0.81.

2.5. Low back pain reports

Subjects were asked to report any episodes of LBP since

playing their last trainee match and to record whether it

affected their golf game (Table 2). The severity of any pain

was indicated by marking the most appropriate descriptor on

the form—‘none, mild, moderate or severe’. Detailed

instructions for completing the questions were provided at

the initial testing session and subjects were given

opportunity to ask questions. Reports were collected in

sealed envelopes by officials from the PGA attending the

trainee matches or by one of the researchers (KE).

Thereafter telephone contact was used to maintain regular

reporting.

The University of Sydney Human Research Ethics

Committee approved the study protocol and subjects gave

consent prior to participation.

2.6. Data analysis

To examine the relationship between the musculoskele-

tal/anthropometric tests and LBP, Pearson’s product

moment correlation coefficient (r) was calculated between

these variables and subjects’ responses to each of the LBP

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130126

questions. Independent samples t-tests were conducted to

compare the means for selected variables for subjects who

experienced LBP with those who did not. For significant

predictors, optimal cut-off points on the ROC curve were

determined using Youden’s index, calculated as sensi-

tivity—(1, specificity) (Biggerstaff, 2000). Analysis was

conducted using SPSS-Windows (Version 10.0.5).

3. Results

Of the 18 subjects who commenced, 14 subjects

completed the reporting requirements of the study. This

sample size was sufficient to give moderate power (O60%)

for correlation values O0.62 and adequate power (O50%)

for correlation values O0.54 (Cohen, 2000). Correlation

values below 0.50 were not considered to be strong enough

relationships with LBP to be worthwhile detecting as

significant.

3.1. Summary of reported LBP

Over the study period, 14 subjects were questioned about

LBP on a total of 267 occasions. Because subjects played

for different amounts of time, the range was from 15 to 31

occasions per subject. During the study, only one subject did

not experience any episodes of LBP. More than half (57.1%)

reported at least one episode of moderate or severe LBP,

28.4% reported moderate or severe leg pain associated with

LBP, 35.7% reported that LBP had moderately or severely

affected their golf on at least one occasion, and six subjects

(42.9%) had to stop playing golf on one occasion because of

LBP. Only two subjects reported that LBP had never

interfered with their golf during the 10-month period.

Further analyses were conducted. Firstly, reports of

LBP were considered as dichotomous data and responses

Table 3

Means (SD) of selected test variables for groups with and without moderate–seve

Variables Mean (SD)

Subjects with LBP (nZ8) S

BMI (kg/m2) 23.4 (2.2) 2

Flexor endurance (s) 166.5 (48.9) 2

Side bridge diffa (s) K19.3 (33.3) 4

Biering-Sorensen (s) 100.6 (42.3) 1

Back extensor MVC (kg) 158.2 (23.8) 1

Right hip MVC (kg) 157.7 (37.7) 1

Left hip MVC (kg) 153.4 (34.9) 1

Right hip flexor length (degrees) 16.5 (33.8) 9

Left hip flexor length (degrees) 11.8 (28.1) 9

Right hamstring length (degrees) 158.1 (16.5) 1

Left hamstring length (degrees) 156.1 (15.5) 1

Right standing rotation (degrees) 115.8 (21.0) 1

Left standing rotation (degrees) 113.9 (16.1) 1

Sit and reach (cm) K1.9 (11.7) K

Self-reported fitness scores (0–6) 4.3 (1.2)

a Side bridge endurance difference (right side bridge minus left side bridge hol

of no or mild LBP were grouped together and considered

the ‘no LBP group’. Those subjects reporting moderate

or severe LBP were grouped together and were

considered the ‘LBP group’. This grouping was used to

conduct independent samples t-tests on the predictor

variables and the results of these are presented in

Table 3. Next, the percentage of time over the whole

10-month tournament period that subjects responded

‘moderate–severe’ for the relevant questions (range,

6–35%) was used to measure the severity of the LBP

problem and was correlated with each of the test

variables.

3.1.1. Relationship of test variables to LBP

Three variables were found to be significantly correlated

with subjects’ responses: BMI, asymmetry on the side

bridge endurance test, and hip flexor length.

BMI was significantly negatively correlated with

percentage of reports of moderate–severe LBP

(rZK0.67; pZ0.01).

Likewise, the magnitude of the difference between left

and right side bridge performance (left minus right holding

time) was significantly correlated with reported LBP

(rZ0.59, pZ0.03). That is, the greater the left relative to

right endurance holding time, the higher the frequency of

reported LBP.

Finally, hip flexor length was significantly and negatively

correlated with perception of LBP affecting golf play or

practice (rZK0.57, pZ0.03). No other anthropometric or

flexibility test was significantly correlated with reports of LBP.

There was no significant relationship found between

performance in trunk extensor or flexor endurance tests and

reported LBP, or between the ratio of trunk flexor to

extensor performance and reported LBP or previous history

of LBP. Hip and trunk extensor strengths were not

significantly correlated with any of the pain responses.

re LBP

Significance, p

ubjects without LBP (nZ6)

7.3 (3.2) 0.02

68.5 (147.6) 0.09

.6 (13.9) 0.16

01 (55.4) 0.99

68.0 (11.0) 0.37

62.0 (20.1) 0.82

51.4 (22.7) 0.91

.5 (33.5) 0.70

.2 (32.3) 0.89

52.3 (14.1) 0.50

53.5 (5.9) 0.70

13.3 (18.4) 0.83

16.8 (17.2) 0.75

0.58 (13.3) 0.85

4.3 (1.2) 0.90

ding time).

Table 4

Sensitivity (Sn), specificity (Sp), and Youden’s index (YI) for body mass index (BMI), side bridge endurance (right–left difference), and hip flexor length

BMI value Side bridge endurance difference Hip flexor length

kg/m2 Sn Sp YI s Sn Sp YI deg Sn Sp YI

20.6 1.00 0 0 K62 1.00 0.00 0.00 K36.5 1.00 0.00 0.00

21.7 1.00 0.13 0.13 K54 1.00 0.13 0.13 K33 0.89 0.00 K0.11

21.9 0.83 0.13 K0.04 K46.5 1.00 0.25 0.25 K28 0.89 0.20 0.09

22.25 0.83 0.38 0.21 K37.5 1.00 0.38 0.38 K25.25 0.89 0.40 0.29

22.9 0.83 0.63 0.46 K25 1.00 0.50 0.50 K21.25 0.89 0.60 0.49

24.35 0.83 0.75 0.58

K12.5 1.00 0.63 0.63 5.25 0.89 0.80 0.69

25.7 0.83 0.88 0.71

K2 0.40 0.63 0.03 29 0.78 0.80 0.58

26.75 0.67 0.88 0.54 3.5 0.40 0.75 0.15 30.25 0.67 0.80 0.47

27.75 0.50 0.88 0.38 11 0.20 0.75 K0.05 30.75 0.56 0.80 0.36

28.3 0.50 1 0.50 21.5 0.20 0.88 0.08 31.5 0.44 0.80 0.24

28.65 0.33 1 0.33 31.5 0.00 0.88 K0.13 32.25 0.33 0.80 0.13

29.85 0.17 1 0.17 36 0.00 1.00 0.00 33.75 0.22 0.80 0.02

32 0.00 1 0 37.5 0.11 0.80 K0.09

41.25 0.11 1.00 0.11

43.5 0.00 1.00 0.00

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 127

3.2. Predictive ability of the variables

Variables that were significantly associated with sub-

jects’ responses were further analysed using ROC curves to

determine relevant cut-offs for clinical recommendations.

Youden’s index was calculated for BMI, side bridge

endurance difference and hip flexor length (Table 4).

Having a BMI of !25.7 kg/m2 or a right side deficit of

O12.5 s were predictors of reports of moderate–severe LBP

and having hip flexor tightness of O58 predicted reports of

LBP affecting subject’s golf game or practice.

4. Discussion

This preliminary study is the first to investigate LBP in

trainee professional golfers, a group of young elite golfers.

These results suggest that LBP is a significant problem for

this specific group, potentially impacting on their ability to

pursue their chosen career. More than half of the study

group (57.1%) experienced at least one episode of LBP

during the 10-month competition season and over one-third

(35.7%) reported at least one occasion where LBP had

affected their golf. Only two subjects reported that LBP had

never interfered with their golf during the 10-month period,

whereas six people (42.9%) reported that they had to stop

playing golf because of LBP. Previous studies have reported

that LBP is the most common musculoskeletal injury

experienced by professional golfers, possibly due to

repetitive play and practice (Gosheger et al., 2003;

McCarroll & Gioe, 1982; Sugaya et al., 1999). Although

no formal attempt was made to record frequency of practice

undertaken, over the course of the study all subjects

completed at least 15 rounds of 36 holes of golf and it is

reasonable to assume that they would play additional rounds

and practise for a considerable amount of time in order to

retain the low scoring average required to successfully

complete a traineeship year. Overuse may therefore be a

significant contributing factor to the aetiology of LBP in

trainee golf professionals.

The strongest predictor of LBP was BMI, which was

inversely related to reports of LBP. That is, relatively tall,

slender golfers were more likely to experience LBP than

relatively short, heavy golfers. These results are consistent

with data reported by Lindsay and Horton (2002) where the

six golfers who reported always experiencing LBP when

playing or practising had a BMI of 24.4 kg/m2 compared

with a BMI of 27.7 kg/m2 for the six golfers who reported

never experiencing LBP. Gosheger et al. (2003) also found

that amongst amateur and professional golfers, a high BMI

was not associated with more golf injuries although golfers

with a BMI of O25 kg/m2 were more likely to report LBP

unrelated to golf. The BMI data for the professionals was

not separately reported and the mean age of their population

was 46.2G17.3 years whereas the present findings were

obtained from an elite group some 20 years younger.

The relationship between high BMI and fewer episodes

of LBP in the present study was not due to trainee golfers

with high BMI being stronger because BMI was not

associated with performance on either of the strength

tests. One possibility, then, is that simply having a larger

overall mass provides a buffer against back injury when

playing golf. According to results obtained here, tall golfers,

who may be able to produce optimal club head velocities

through a long swing arc, also need to have larger muscle

mass or a heavy build in order to protect their lumbar spine

from injury. Another possibility could be that tall, slender

golfers achieved greater ranges of movement during the

swing, thereby potentially increasing the loads on their

lumbar spine. Shorter, heavier golfers may be able to

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130128

achieve optimal swing mechanics with minimal force on the

lumbar spine through efficient momentum transfer (Okuda,

Armstrong, Tsunezumi, & Yoshiike, 2002). These alterna-

tive accounts require further examination.

Performance on the side bridge test was associated with

reports of LBP but there was no association between the

tests of trunk extensor or flexor endurance and LBP.

Subjects whose left side bridge endurance time was greater

than the right by O12.5 s were more likely to report

episodes of LBP in the subsequent 10-month period. The

relevance of this test as a predictor for LBP in golfers may

be related to the asymmetrical nature of the golf swing,

which subjects the lumbar spine to extremes of asymmetric

motion and rapid and complex loads, particularly during the

downswing (Hosea, Gatt, Galli, Langrana, & Zawadsky,

1990; Sugaya et al., 1999). For example, in a right-handed

golfer, trunk motion occurring during the downswing and

acceleration phases involves a combination of left axial

rotation and right lateral bending. The right abdominal

oblique muscle has been found to be particularly active

during the acceleration phase of the swing on EMG (Hosea

& Gatt, 1996; Watkins, Uppal, Perry, Pink, & Dinsay, 1996)

and Sugaya et al. (1999) reported that right-handed

professional golfers were more likely to experience pain

on the right hand side of the lumbar spine. It has been

suggested that golfers, like other athletes, exhibit adaptive

changes that have developed in response to the demands of

their sport (Vad et al., 2004) and therefore golfers who play

more frequently may require better endurance of the

muscles on the dominant anterolateral aspect of the trunk

to produce a smooth, consistent, powerful swing in an

injury-free manner. Alternatively, Lindsay and Horton

(2002) found that golfers with LBP had greater left side

bend during the backswing than golfers without LBP.

Golfers with LBP who were consistently producing greater

left side bend during the swing may therefore develop better

endurance of the trunk muscles producing this motion,

reflected in better performance on the left side bridge

endurance test. However, in the present study, there were

two left-handed golfers. One of these could not complete a

right side bridge endurance test due to an acute shoulder

injury so was not included in the data analysis. The other

left-hander had two occasions of LBP and on one occasion,

had to stop playing golf due to LBP. This subject’s left and

right side bridge holding time was 96 and 35 s, respectively,

data which implies that his dominant side had better

endurance. Further analysis could not be undertaken to

examine handedness effects because there were too few

subjects for sub-group analysis. Subsequent studies with

larger populations are required to clarify these findings.

Consistent with previous findings (e.g. Holmstrom,

Moritz, & Andersson, 1992), trunk extensor strength was

not correlated with trunk muscle endurance and was only

weakly inversely correlated with reports of LBP. Trunk

extensor strength may be important for improving driving

distance and clubhead speed (Fletcher & Hartwell, 2004)

but good trunk extensor strength has not been clearly

shown to prevent LBP. In the present study, only trunk

and hip extensor strength was examined. Whether the

strength of other muscle groups important in the golf swing

(e.g. abdominals) relates to reports of LBP should be

evaluated in future studies.

A measure of the impact of LBP experienced by trainee

professional golfers is the effect LBP has on their golf game

or practice. During the 10-month period, only two subjects

reported that LBP had never interfered with their golf game

and over one-third (35.7%) reported that LBP had affected

their golf on at least one occasion. Six people (42.9%) had to

stop playing golf because of LBP. Of the variables tested in

this study, golfers with relatively shorter hip flexors were

more likely to report that they felt LBP had affected their

golf game or practice. Vad et al. (2004) found that

professional golfers who had experienced LBP in the

previous 12 months had reduced range of internal rotation of

the lead hip, FABERE’s distance and lumbar spine

extension range compared with asymptomatic golfers. The

present study did not examine hip internal rotation range or

FABERE’s test, but found no relationship between lumbar

spine range of motion and future episodes of LBP.

This study has clinical implications for therapists

working with golfers whose aim is to minimise risk of

LBP. First, an above-average BMI seems to be helpful in

preventing LBP. As there are negative health consequences

associated with increasing percent body fat, the implication

here is for golfers with a BMI below 25 kg/m2 to use

resistance exercises to add more overall muscle mass.

Second, if their left side has better endurance, to improve

right side bridge endurance, by training in the manner of the

test (Axler & McGill, 1997; McGill, 1998). Finally, we

found that tight hip flexors were not associated with

frequency of LBP episodes, but were related to perceiving

that LBP affected golf performance. Intervention to increase

hip flexor length may therefore be useful and at worst the

consequences of improving hip flexor length are benign.

Fradkin, Sherman, and Finch (2004) found a significant

increase in clubhead speed for golfers who underwent a

5-week warm up conditioning program. The specific

stretches were not outlined but data from the present study

suggest that incorporating a hip flexor stretch into such a

routine may also be beneficial.

5. Conclusion

LBP is a significant problem for trainee professional

golfers. In this prospective study, over half experienced at

least one episode of moderate–severe LBP during the

10-month period and 35.7% reported at least one occasion

where LBP had affected their golf. Of the measures taken,

having a normal or low BMI and a right side deficit on the

side bridge endurance test independently predicted future

episodes of LBP, with BMI being the strongest predictor.

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 129

Golfers with tight hip flexors were more likely to report that

LBP affected their golf game or practice. The findings here

may all be explained as consequences of the repetitive

biomechanical demands of the golf swing and although

further research is needed, current data support the inclusion

of these tests in a musculoskeletal examination of a trainee

professional golfer. The other variables examined in this

study, however, cannot be excluded as being unrelated to

LBP in golfers without further studies involving larger

groups.

Acknowledgements

The authors wish to thank the Australian Professional

Golfer’s Association of Australia for their assistance with

this project.

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