February 2012

Hip rotation in golfers may determine pathology

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Golfers demonstrate significant asym­metries between hips with regard to rotational range of motion and rotational velocity, which can contribute to the development of conditions including low back pain, femoroacetabular impinge­ment, and hip labral degeneration.

By Heather Gulgin, PhD, ATC    

Sports are an integral part of every culture, with people participating from early childhood all the way through the late adult years. From the weekend warrior to those at the professional level, sports are a way of life for millions. Over time, each sport places specific demands on the musculoskeletal system, which may result in tissue adaptation and overuse injuries. For example, some retired professional athletes now live with the consequences of the “wear and tear” on their body’s soft-tissue structures (such as cartilage) as a result of the accumulated stress placed on the body.

Shepard1 reported a significantly higher prevalence of hip osteoarthritis (OA) in former professional soccer players than in age-matched controls. Interestingly, none of the athletes surveyed reported an actual hip injury during their playing years. Likewise, Tveit et al2 also found a higher rate of hip OA in former elite male athletes participating in impact sports (football, rugby, soccer, and handball) compared with controls. Thus, joint pathology is not necessarily dependent on a history of an acute injury to a particular body region. Some injuries may result simply from repetitive movement and loading patterns over time.

Athletes often utilize repetitive movements to perform the skills required throughout a match or game. Some sport movement patterns occur bilaterally or have the potential to occur on both sides with equal frequency. For example, a tennis player may use right and left directional trunk rotations during various shots (backhand and forehand) throughout a match. However, in certain sports, one side of the body experiences movement patterns that the other side does not during the required sport motion. If the same tennis player is right-hand dominant, for example, he or she will experience more overhead movements in the dominant shoulder than the nondominant shoulder as a result of the serving motion. It is not uncommon for overhead athletes (throwers and servers) to demonstrate a bilateral difference in upper extremity range of motion (ROM) as a result of the repetitive demands on the dominant arm relative to the contralateral side.3,4

An example involving the lower extremity is that baseball hitters who bat only right-handed will always have the left hip facing the pitcher. Thus, all of the lower body rotation occurs around the left (or lead) hip during the hitting motion. Similarly, every golfer has a dominant hand with which he or she plays, and thus will have the same lead hip experiencing all the rotation during the follow-through phase of the golf swing. Until recently, little was known about ROM changes in the lower body as a result of repetitive, unilateral movement patterns.

Hip ROM asymmetry

In golf, since the lead hip experiences more rotation than the trail hip on both the takeaway and downswing phases of the golf swing,5 we might expect to see an adaptation in the ROM. Two studies6,7 have shown that indeed there are some side-to-side differences in hip rotation ROM in professional golfers as a result of their sport participation. Vad et al6 examined Professional Golfers’ Association (PGA) players and found significantly less internal rotation in the lead hip than the trail hip in the sample group with reported low back pain (LBP), and a trend for this occurring in the non-LBP group. They hypothesized that the eccentric action of the external rotators during the downswing creates microtears in the muscle, resulting in an adapted shortened and tightened state. Thus, if the external rotators become shortened, this will limit the amount of available internal rotation.

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Gulgin et al7 measured hip rotation ROM in 31 LPGA (Ladies’ Professional Golfers’ Association) players. Eight of the golfers had a side-to-side difference of more than 5° for internal rotation (IR) ROM. Additionally, 10 golfers had a side-to-side difference of more than 5° for external rotation (ER) ROM. Thus, almost one fourth of the LPGA golfers tested had a bilateral IR ROM asymmetry and one third had an ER ROM asymmetry. Gulgin et al7 also reported on those with and without LBP, finding that the golfers without LBP had bilateral symmetry for IR, but those with LBP had a slight difference in IR.

A recent study by Murray et al8 examined hip rotation ROM in amateur golfers (men and women) covering a large age span and reported a significant reduction in lead hip IR (approximately 10º) in the sample population with self-reported LBP compared with controls who did not report LBP.  What remains unclear is whether the loss of hip IR motion on the lead hip is occurring as a result of existing LBP or from the repetitive motion of the golf swing causing changes in the surrounding soft tissue. None of the studies just mentioned can definitively determine if the reported back pain made the difference in participants’ measured ROM, or whether their asymmetry was pre-existing and contributing to development of their LBP.

However, the asymmetrical hip ROM reported in the golfing population has considerable clinical relevance since there is already an established correlation between hip rotation ROM asymmetry and LBP in the general population.9 Golf injury surveys have reported that the leading injury among both professionals and amateurs involves the back region.10-15 Researchers have also reported that IR is the first movement restricted in early arthrosis of the hip.16

Currently, the author is aware of two world-class professional golfers (Jack Nicklaus and Tom Watson) who have had a total hip replacement on their lead hip.17,18 Thus, although the bilateral joint ROM for those professional golfers prior to surgery is unknown, early detection of any loss of IR ROM may alert the clinician of more serious underlying joint pathology, underscoring the importance of bilateral assessment of hip rotation ROM.

Hip injuries in golfers

Interestingly, hip injuries have ranged from low to unreported on most injury surveys on amateurs and professionals in the past.10-15 Recently, however, the occurrence of tears in the athlete’s acetabular labrum have been reported in sports that place rotational demands on the hip (such as tennis, golf, and hockey).19-21 It has been suggested that the mechanism for an acetabular labral tear is excessive hip external rotation with extension.22 However, one orthopedic surgeon reported that, in 55 patients from the general population examined over a 19-year period, only a small number of labral tears had a specific event or cause of injury.23 This suggests that a majority of labral tears are atraumatic, with repetitive forces being responsible for the injury.

Andrews et al24 reported on repetitive overhead activities (pitching, tennis, swimming), and the relationship with glenohumeral labral tears. These authors suggested that repeated overhead activity with increased anterior-posterior humeral head translation may result in labral fraying, and that large eccentric forces of the biceps tendon may pull away the labral complex. For example, it has been reported that baseball pitchers achieve a humeral rotational velocity of 7000°/s in the throwing motion.25 Thus, it would only be appropriate to consider that similar accumulative rotations on a fixed lower extremity could possibly cause an avulsion or fraying of the acetabular labrum, even if at a lower velocity with smaller forces.

The golf swing is a very quick movement, with the typical backswing taking 0.8 to 0.91 seconds, and the downswing lasting only 0.29 to 0.38 seconds, for a total swing time ranging from 1.09 to 1.28 seconds among professionals and amateurs, respectively.26 The rapid downswing phase, during which the trail hip experiences ER and extension, may be the “danger zone” for labral tears to occur in the trail hip. Although the literature suggests ER and extension as a possible injury mechanism for the acetabular labrum, the author is only aware of two professional golfers who have experienced a labral tear in the trail hip.

Hip rotational velocities

Just as studies of the throwing motion have examined upper extremity rotational velocities,25 studies have also quantified lower extremity rotational velocities.27 However, these researchers have assessed a lower limb moving in an open kinetic chain, such as the kicking leg. Very few studies have examined the lower body rotational velocities achieved at the hip joint while the foot is fixed (closed kinetic chain). One such study found that when hitting a baseball, the rotational velocity at the hip reaches a maximum speed of 714°/s (0.075 seconds prior to ball contact).28

It should be noted that the investigators defined hip motion as a vector from the right to the left hip, which could be more accurately described as movement of the entire pelvis, rather than separate hip (pelvic-on-femoral) rotation that would occur on each side. Like the baseball hitter, whose front foot is fixed as weight is transferred onto it during the hitting motion, golfers also experience rotational velocities at the hip in a closed kinetic chain.

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Although kinematic data on the throwing motion in baseball support potential mechanisms for labral tears in the shoulder, the literature to date has lacked similar data on the velocity of the lead and nonlead hips during a full golf swing to determine if the same type of mechanistic potential exists for labral pathology in the hip. Gulgin et al29 examined the hip rotational velocities of collegiate female golfers during the golf swing and found the lead hip experienced significantly higher rotational velocities than the trail hip (227.8°/s vs 145.3°/s). These rotational velocities of the hip measured by Gulgin et al29 are much lower (227.8°/s) than the study28 that examined “hip rotational” velocity by essentially calculating the pelvis movement (714°/s).  It should be noted that the participants in Gulgin et al29 were women and Welch et al28 studied men, thus the difference in rotational velocity may have also been due to the gender difference.

With regard to golfers the question becomes, is this enough rotational velocity to cause a labral tear or fraying during the golf swing? Since the expected mechanism for an acetabular labral tear is extension and ER, we would expect to see more labral tears in the trail hip than the lead hip. But the lead hip experiences higher rotational velocities, so could a golfer tear the labrum of the lead hip?

A recent study by Kang et al30 suggests that athletes with existing femoroacetabular impingement (FAI) may be even more susceptible to acetabular labral tears. Thus, by pure anatomy, some golfers may be prone to labral tear during a movement, regardless of the velocity of movement, if they are put in an impingement position (flexion and IR). Professional golfers Kris Tschetter and Greg Norman have torn their lead hip labrum. The golf swing would place the lead hip in a slightly flexed and IR position as coming through impact of downswing. However, this is not any where near the 90º flexed position required for the impingement injury mechanism suggested by Ganz et al.31 Keogh and Batt32 report that the etiology of FAI is unclear and it is not known if certain sports induce femoral neck abnormality (cam-type impingement) through osteophytic formation or simply exaggerate an existing problem by utilizing specific ROM during loaded movements, such as those occurring in sport.

Philippon et al33 have reported that all professional hockey players in the study who were treated for labral tears had evidence of FAI. This is a sport that has a high rotational torsion component on the hip, but also requires the skater to be in a more crouched position of hip flexion and IR compared with golfers who experience IR on the lead hip during the downswing with a more neutral hip position or slightly flexed position. As mentioned, World Golf Hall of Fame members Nicklaus and Watson have both had total hip replacements on their lead hip, but it is unknown whether they also had evidence of labral tears or FAI at the time of surgery. One surgeon believes these pre-existing pathologies are part of a continuum of degenerative joint disease.21

It would be interesting if this continuum does indeed exist, and if so, whether at the point the clinician detects a loss in hip IR it is too late to intervene. Might every golfer who exhibits a loss in lead hip IR be showing signs of serious joint pathology, or simply an adaptation in surrounding soft tissue due to the repetitive motion of the golf swing?

Despite the measured hip rotational velocities at the hip not being as high as those measured in overhead activities, we need to remember that the throwing motion is an open kinetic chain for the upper extremity, and the golf swing is a closed kinetic chain for the lower extremity. Thus, even at this level of rotational velocity, the downswing movement may produce sufficient torsion on the hip to predispose the joint to injury.

Gulgin et al5 considered whether golfers might be exceeding their available joint ROM while weightbearing during the golf swing, which might place them at risk for soft-tissue injury. Interestingly, most activities of daily living, as well as sports, involve weightbearing for a majority of the time. However, when clinically assessing available joint ROM, either passively or actively, measurements are frequently performed while the patient is non-weightbearing. For the athlete, a more functional assessment in a weight-bearing position may be required to determine if there is an adequate amount of hip rotation ROM necessary for a particular sport, skill, or motion. If golfers exceed their available weight-bearing hip rotational ROM limits during the golf swing, they would be increasing stress on the surrounding soft tissue and increasing risk of injury.

Gulgin et al5 investigated the weight-bearing internal and external hip rotation ROM limits in collegiate golfers and compared this with the actual amount of hip rotation utilized during the golf swing. In general they found golfers do not exceed their available weight-bearing ER hip rotation ROM limit on either hip when measured in a stance position that matches their golf address posture. However, if golfers have their hip and knee posture in a more erect position (such as at point of follow-through onto the lead leg) they could begin to exceed the lead hip IR ROM available, putting more stress on the surrounding soft tissue.

Discussion of findings

Research has indicated that golfers do exhibit hip rotation ROM asymmetry. Hip rotation ROM asymmetry has already been correlated with episodes of LBP, but could also be an indicator of more serious joint pathology (i.e., labral tears, early degeneration, OA). Therefore it is of great clinical importance to examine bilateral hip rotation ROM as part of any golfer’s pain and injury assessment. Although golfers do not experience rotational velocities at the hip as high as those associated with the upper extremity in overhead sports, repetitive golf swings could be contributing to ROM changes and possibly even labral tears and fraying, FAI, and early degeneration.

Interestingly, much of sport occurs with the lower extremity in a weight-bearing situation, yet we have had no normative data for hip rotation ROM under these conditions, nor have studies tested athletes to determine whether they have enough weight-bearing ROM for the sport they play. With regard to concerns that golfers may be exceeding their weight-bearing ROM limits during the golf swing, specifically on the lead hip, the investigation by Gulgin et al5 was important in determining that golfers do not exceed the ER weight-bearing hip rotation ROM available on either hip, though they may exceed the IR limit on the lead leg. Over time, this repetitive IR movement during the downswing, which may go beyond a golfer’s measured “norm,” may be allowing for the change in ROM on the lead hip.

Heather Gulgin, PhD, ATC, is a certified athletic trainer and assistant professor at Grand Valley State University in Allendale, MI.    


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