By: Erin Hurley Booker
Tiger Woods knows the importance of taking care of his knees. Just this past April, Tiger underwent his third knee surgery since 1994. He has since then spent a tremendous amount of time rehabbing the left knee in preparation of returning to golf, hoping to come back stronger and more accurate than ever in time to participate in tournaments late May or early June.
Tiger’s surgeries have been to the left knee, which is the more commonly injured knee for a right-handed golfer. Second to the low back, the knee is the most commonly injured joint in golf. Knee pain or injuries can significantly alter swing mechanics and, therefore, result in poor ball placement and higher scores.
There are numerous common knee injuries related to golf. Basic knowledge of knee anatomy is required to understand golf-related injuries. Below is a list and brief description of the main anatomical parts of the knee joint.
Bones – The knee is made up of three bones: the femur, which is the large thigh bone; the tibia, which is the shin bone; and the patella or kneecap.
Muscles – The muscles that run across the knee joint are extremely important in not only moving the knee but also in protecting it and absorbing shock. The main muscles include the quadriceps, or thigh muscle, which extends the knee forward; the hamstring, which sits behind the thigh and bends the knee; and the calf muscle, which pushes the foot down and works at the knee as the hamstring’s assistant to bending the knee. There are other small muscles that run from the back of the knee into the foot. These muscles work to rotate the knee at the end of straightening to help lock it in that position.
Ligaments – There are four main ligaments that support and prevent excess motion at the knee. The most famous (or notorious, especially in sports injuries) is the ACL, or the anterior cruciate ligament. Its counterpart is the PCL, or posterior cruciate ligament. These two ligaments run between the femur and tibia under the patella, and help prevent excess forward or backward movement of the knee. The MCL, or medial collateral ligament, is a wide ligament that runs on the inside of the knee connecting the femur and tibia. The forth ligament, the LCL (lateral collateral ligament), is on the outside of the knee joint. These ligaments are important in side-to-side movements.
Cartilage – In between the femur and tibia sit two C-shaped meniscus, or cartilage. This cartilage acts to distribute shock between the lower and upper leg and help guide the motion at the knee.
Now that we have a basic understanding of knee anatomy, let’s discuss common injuries or problems associated with the knee.
Osteoarthritis (OA) – OA is the most common knee problem and the second leading cause of disability in Americans over the age of 65. OA is the “wear and tear” of joints, and is often the result of poor mechanics. This can be due to tight and/or weak muscles, previous injuries to the joint, and overuse of the joint. Signs and symptoms of OA include stiffness and swelling that is worse in the morning or after resting, and improves slightly with activity.
Condromalacia (CM) – CM is “wear and tear” or softening of the undersurface of the kneecap. Similar to OA, CM can be a result of poor mechanics at the knee joint. Dull pain and/or grinding are often felt under the kneecap, and the pain is worsened with hills or stairs.
Torn Ligaments – Strains or tears (partial or full) are common with activities that involve sudden starts/stops and pivoting. Ligament injuries such as ACL tears are often seen in basketball, soccer, and football. With a ligament injury, a loud “pop” is often heard. There may or may not be pain associated with a full ligament tear.
Meniscal Injuries – The meniscus is often injured with twisting or pivot motions. Because the meniscus lacks good blood supply, they do not heal as most other tissue does. Meniscal injuries often cause clicking and catching sensations in the knee, especially with squatting or bending.
Tendonitis – Tendons often become inflamed and irritated due to overuse or improper use of muscles. Tendonitis is especially common in those just starting out in a new activity, or when changing form when not enough time for rest is allowed.
There are various causes of knee problems related to golf. Many of these problems are related to the amount of rotation throughout the body that is required during the backswing and follow-through. For a right-handed golfer, a significant amount of torque and valgus stress (stress to the inside of the knee) is generated at the left knee. The knees must stay flexed during the backswing to absorb some of the rotational stress of the swing. For the many golfers who have tight back muscles and joints, one of the ways to attempt to generate more turn in the backswing is to place more stress on the knee. This often leads to injuries to the medial (inside) meniscus. There are also many golfers with tight hip muscles, which changes the joint alignment at the knee. This again places more stress on the knee, making it more susceptible to injury. Another possible cause or contributor to knee pain is poor fitting or poor supporting shoes. Golf shoes that do not provide enough arch support can lead to a pronated foot position (flattened arch), which places the knee in a rotated position. Over the course of walking 18 holes, or up and down hills and through sand traps, this foot and knee position can lead to a significant amount of knee pain.
The knee is not designed well for the rotation and side-to-side movement required by the golf swing. Because of this, precautions should be taken to ensure that extra stress is not placed on the knees. One of the best measures to take is to ensure that the muscles in your hips, low and mid back are flexible. By allowing full rotation to occur through the hips and back, stress is evenly distributed about the knee, and will not cause any extra injury. It is also important to make sure that the three main muscles surrounding the knee joint are strong. By making certain that these three main muscles are strong and the hips and back are flexible, the knee joint is afforded maximal protection against injury. Your Physical Therapist or personal trainer can help you with flexibility and strengthening exercises to target these areas to decrease stress on your knees.
If you are recovering from a knee injury, there are some tips for your preliminary return to playing golf. I always advise my patients to practice at the driving range up to several weeks prior to playing 18 holes of golf. While first starting back to the range, I advise them to start with their wedges and shorter irons. I have them start with short swings, working up toward their full swing, and then eventually into their longer irons and driver.
I also advise my patients to wear spikeless shoes upon their first return. The shoes should have good arch support to prevent knee rotation. There are many specialty golf shoe and sneaker stores than can fit you with over-the-counter arch support for your sneakers and golf shoes if needed. In some cases, custom-made orthotics from your healthcare professional may be required to provide optimal foot positioning. Orthotics can potentially help the knee, but also decrease strain on the hips and back.
Many patients often ask me about knee bracing, either preventatively or after a knee injury. My advice is usually the same: Knee braces are good for providing temporary support after a mild injury, but should not be worn long-term. Any brace that is worn long-term may cause the body to rely on that extra support, and can actually weaken or suppress the structural support system.
As always, any injury that prevents you from playing or walking normally, or lasts longer than a few days needs to be examined by your healthcare professional. Playing through a knee injury can actually worsen the injury or lengthen the recovery time needed to get back on the course. Remember, strong knees and flexible back muscles help ensure smooth movement through the entire backswing and follow-through, helping to make your shots go straighter and longer.
Erin Hurley Booker, MPT, is a GFM Advisory Team Member and Clinic Director for Physiotherapy Associates, in Ocoee, Florida. For further information on Erin, log onto www.golffitnessmagazine.com/advisoryteam.
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