The golf swing imparts a tremendous amount of stress to the lumbar spine. This is related to the torque that is generated in the windup and follow through of a long iron or wood shot. Injuries to the lower spine are quite common in both amateur and professional golf. In fact, back injuries are the most commonly reported ailments of frequent golfers.
Many pros have been hampered by low back problems during their careers, including Freddy Couples, Rocco Mediate, Ken Venturi, Lee Trevino, and others. Some of these talented professionals have even undergone low back surgery for their problems.
The good news is that despite the high incidence of spine injuries among golfers, the majority of these people have returned to swing again and swing well.
Interestingly, very little has been described in literature specifically on golf and the spine. The points and recommendations in this article are only guidelines. They represent an amalgam of protocols that spine surgeons experienced in treating amateur and professional golfers have created based on their experiences. It is important to emphasize that every patient is unique, and some patients may have specific limitations or anatomical pathology that does preclude returning to golf altogether. Fortunately, the majority of patients can return to the links after spine surgery provided they have an adequate recovery time.
Recovery periods and activity limitations vary greatly depending on the type of surgery performed. In general, the two most common operations performed on the lumbar spine are discectomy and lumbar fusion operations. These two procedures vary greatly in terms of the length of recovery and how quickly one can return to sports activities.
Lumbar Discectomy or Microdisectomy
Because a lumbar discectomy removes the pressure on a pinched nerve and causes very little disruption of the spine joint, one of the main guides to returning to the links is how the patient feels. Typically, if a patient is experiencing a good recovery, he or she can begin flexibility and strength training for the low back and abdominal muscles at about four weeks after surgery. These exercises should be supervised by a physical therapist who understands the mechanics of the golf swing. Depending on the level of the player, easy swinging with short irons can commence at about six weeks after surgery.
Arthur Day, M.D., a neurosurgeon at the University of Florida who has treated many professional golfers, points out that his recommendations regarding return to play differ significantly between the weekend warrior and the professional player. “Because the pro imparts such a tremendous amount of torque on their spine compared to the amateur, I tend to keep pros from even touching a club for about three months. The average golfer tends not to transmit the same kinetic energy to their spine and, therefore, can return to swinging earlier, provided they are making a good recovery.”
Once the patient has mastered low back flexibility and strengthening exercises and has returned to light swinging with short irons, they can proceed with advancing to a full swing. “I always emphasize to my patients that they must develop good stretching habits before and after playing,” says Peter E. Sheptak, M.D., vice chairman of the Department of Neurosurgery at the University of Pittsburgh and a well-known surgeon for professional athletes. “Also, in the first three months of their recovery, I never let them hit a rough or sand shot. The point is, when they are recovering, they have to avoid hitting the ball fat, which can result in a re-injury.”
Regis W. Haid Jr., M.D., chief of Spine Surgery at the Emory Clinic, also imparts several rules to his patients when they return to golf after lumbar discectomy. “I tell my patients to walk, don’t ride a cart, and don’t hit off the tee until about 12 weeks after the surgery.” Haid points out that by following these recommendations, his patients get more exercise and avoid swinging too hard, yet still can enjoy the golf outing.
At 12 weeks after surgery, most sports medicine-oriented surgeons will allow their patients to return to the links but only for shorter, nine-hole outings. It is important for patients to understand that endurance must be regained prior to embarking on a full round of 18 holes. Usually by 16 weeks after surgery, patients can return to a full round of golf.
If a patient at any time experiences a flare-up of symptoms, they should put their regimen on hold for at least four weeks and then begin back at step 1 with strength and flexibility exercises.
Fusion operations typically require a two- to three-month period of back external immobilization (bracing) to help the bone graft and fusion solidify. In order for the fusion mass (bone mass) to solidify, movement must be kept to a minimum. The metal screws and rods placed to augment the fusion act as an internal brace to maximize stiffness in this region. This internal immobilization is often combined with an external back brace (either hard plastic or soft girdle with support panels) and sometimes a bone fusion stimulator as well.
During the first 12 weeks after surgery, extensive range of motion is limited to allow bone healing. Although the initial internal metallic construct is strong, over time it could ultimately fail if bone cells (osteoblasts) don’t migrate into the fusion area and form a new bone matrix in and around the hardware. The metallic screws and rods act like rebar, whereas the in-growth of bone offers the true concrete that creates a lasting solid fusion.
During the first 12 weeks, activity should be limited to walking only. Three months after surgery, X-rays are obtained to verify that the fusion is in progress. If the X-rays show evidence of an advancing fusion, the brace can be discontinued.
During the post-operative period between weeks 12 and 16, usually only a light stretching regimen is initiated. This consists of abdominal and low back muscle stretching. After 24 weeks of recovery, I typically will allow patients to begin swinging short irons at the practice range if they are doing well and are experiencing a good recovery from their pre-operative symptoms. Light swinging at 24 weeks after surgery is not universally accepted; some surgeons recommend a longer convalescence. In fact, some spine surgeons like to keep their fusion patients off any swinging regimen until a full six to nine months of recovery have been completed.
“For my fusion patients, I really like to start them back very slowly,” Day said. “I keep them from swinging for six months after their surgery, and then we start from scratch with stretching and flexibility.”
Gerald Rodts, Jr., M.D., a well-known sports medicine spine surgeon (neurosurgeon) at Emory University, emphasizes that golf rehabilitation after fusion must be individualized. “Treatment must be tailored to the individual patient and what their overall clinical situation mandates. Since some patients don’t even begin to see the benefits of their fusion until six to nine months after the operation, a good population of these patients will not be ready to return to swinging until a six- month recovery period.”
He adds, “if, however, there is good X-ray evidence of a maturing fusion at 16 to 20 weeks after surgery and the patient’s symptoms have resolved, I feel it is probably safe for them to begin their golf rehabilitation at 20 weeks post-operatively.” If all is well at 24 weeks after surgery, he encourages his fusion patients to return to light swinging with the proviso that any flare-up of pain is an automatic pause for the golf rehabilitation phase until a total of six to nine months have passed since surgery.
The importance of warm-up and cool-down periods that consist of easy stretching and a range of motion exercises cannot be overemphasized. This is part of ‘low back maintenance’ and needs to be considered a part of life for any patient with back pain. I try to emphasize to my patients that back stretching and warm-up are like flossing your teeth or warming your car up in cold weather. They are things that one must do every time as a routine.
If the patient continues an uneventful recovery, they can be advanced to mid-range iron shots with light swinging at 24 weeks post-op. This can be advanced to the long irons and woods by 28 weeks. A controlled range practice with limitations on number of balls hit is safer and easier on the recovery compared to embarking on a round of 18 or even nine holes.
When playing ‘live golf,’ players are often faced with a variety of shots that require them to alter their stance, posture, and leg position. In addition, the varied surfaces, i.e. thick vs. thin rough, downhill or uphill lies, and sand, present too varied a swing resistance for the recovering patient. Most often it is not the predicted movement or swing that causes injury or recurrent injury, but the unpredicted shift in weight, accidental turn, or unexpected resistance during the swing that is the recipe for trauma. Probably the most common statement on the injured golfer heard in clinic is: “I hit the ball fat, doc, and that’s when my back started to flare up.”
At 28 weeks after surgery, patients can begin to play short, nine-hole rounds of golf. It is important again to emphasize to patients that they should strictly adhere to only nine holes because as one fatigues, the potential for re-injury increases. When playing, patients should not hit thick rough shots or angled lies. These ball positions should be avoided completely during the recovery phase. If you ever wanted a doctor’s excuse to carry out on the course with you to give you a special dispensation, this is the time to do it. Sand shots can be allowed, but only from shallow traps. Deep bunkers should be avoided at all costs, as the power necessary to extricate a ball from this treacherous region could undo all the good work your surgeon performed some 28 weeks ago.
Mark McLaughlin, M.D. practices neurosurgery at the Neurosurgical and Neurological Group in Springfield with a focus on sports-related spine surgery. He is on the editorial board of spineuniverse.com, a Web site dedicated to patient and physician education on spinal disorders, from which this article was reprinted.