Golf is a popular and growing recreational activity in the United States. In 2024, golfers played 545 million rounds, compared to 531 million rounds in 2023. Golf has established physical and mental health benefits. A 2008 study from Sweden showed that golfers have a 40% decrease in all-cause mortality. This means they were 40% less likely to die during the duration when compared to their non-golfer counterparts. While the authors cannot conclude with certainty that these findings were caused by the physical activity associated with golf, there seems to be some influence. In my opinion, the mental and social aspects of the game are most likely contributing factors in lowering the risk of dying. Another interesting pearl from this paper is lower handicaps had the lowest mortality rate. If you never needed a reason to play more golf, there it is.
Low Back Pain Statistics: Golfers vs General Population
Low back pain is the most common ailment affecting golfers. However, the mechanisms of what causes low back pain are poorly understood. In recreational golfers, the incidence of LBP ranges anywhere from 12.4-26.9%. In professionals, it has been reported that 40-58.1% of golfers experience low back pain. That sounds like a lot, but back pain is common. The one-year point prevalence of low back pain is estimated at 15-20%; meaning 15-20% of adults experience an episode of LBP during a calendar year. Further, 80% of people will experience an episode of debilitating low back pain at some point in their lifetime. In the vast majority of cases, acute low back pain will resolve completely over a period of weeks to months. This recovery can be accelerated with a multimodal approach of education, exercise, stretches, and pain pacing strategies.
Predictors of Low Back Pain in the General Population
In the general population, there are a number of things that predispose someone to experience LBP. These include:
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Prior history of LBP
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Older Age
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Low Activity level
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High Body mass index (BMI)
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Smoking
Hypothesized Predictors of Low Back Pain in Golfers
It has been hypothesized that the complexity, repetitive nature, and high forces involved in the golf swing can contribute towards LBP in golfers. Although golf is typically thought of as a low-impact activity, the golf swing generates a lot of force that the body accepts and uses to transfer energy from the ground, through the body, and into the club. That being said, there is a plethora of contradictory research on the golf swing and its effects on back pain, and the jury is still out on causative factors associated with LBP. A systematic review and meta-analysis investigated these relationships, hoping to outline specific factors that contribute to this frustrating and common condition.
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X- factor: This is defined as the separation between the shoulder girdle and hip girdle, particularly at the top of the backswing. Elite golfers are able to create a sizable dissociation between the angle of their shoulder girdle and hips. The best golfers initiate hip rotation towards the target at the top of their backswing, making the X-factor the largest just after the backswing. A larger X-factor has been associated with increased swing speed, and is common among elites. It has been hypothesized that a larger difference between the shoulder and pelvic girdles could be a contributing factor towards low back pain in golfers.
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Crunch factor: This refers to the compression of the spinal discs during the golf swing. This occurs during the rotation and lateral bending of the lumbar spine through the golf swing, particularly at impact.
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Golfing Frequency: how many days per week one golfs
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Mobility limitations: Many of the studies included in the review looked at mobility restrictions in the legs, hips, spine, and shoulders.
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Strength limitations: Weakness in the muscles
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Movement Coordination: A few of the studies investigated the onset of different back and leg muscles during different parts of the swing.
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Handicap: Golf skill level
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Body Mass Index
What did they find?
After combing through all the research from the selected studies, findings were as follows:
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Peak X-Factor
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Conflicting evidence that x factor contributes to low back pain. Onl 2 studies examined this, with conflicting results. The authors were unable to conclude that x-factor has an impact.
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Crunch factor
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No evidence that peak crunch factor is a contributing factor. In the 2 studies that measured peak forces on the lumbar spine, there was no significant difference in crunch factor in individuals with and without LBP.
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Golfing Frequency
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Conflicting evidence that golfing more often contributes to back pain. Some studies showed more practice hours equated to more back pain, while others show the opposite. In my opinion, this is a tissue capacity issue, and could potentially be mitigated by graded exposure to more golfing.
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Mobility Limitations
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Some evidence that reduced hip ROM can contribute to low back pain. Specifically, golfers that had limited lead hip (left hip in a righty golfer) mobility potentially increasing the forces in the spine and leading to more pain. However, the authors state that there is not enough evidence to state this is significant.
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Strength Limitations
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Some evidence found in multiple studies that showed a relationship between trunk and leg muscle weakness and LBP. However, many of the studies measured different things. Additionally, people with LBP in the general population often have muscle weakness. The authors were unable to make a direct connection between specific muscle groups, though core and leg muscles were shown in a couple studies to be weaker in the LBP groups.
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Movement Coordination
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Some evidence that the timing and function of back and leg muscles are associated with more LBP. Again, there was limited evidence to suggest that these factors are consistently associated with golfing-related pain.
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Handicap
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No evidence that handicap affects incidence of LBP
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Body Mass Index
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Some Evidence that higher BMIs were associated with increased low back pain. However, this is also true in the general population, and the reasons for this are multifaceted. For example, increased body mass could be a result of decreased physical activity because of pain.
The strongest predictors of low back pain in golfers?
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Prior history of low back pain
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Age
Interestingly, these findings mirror the strongest predictors of low back pain in the general population. There are an abundance of other factors that contribute towards low back pain that were not accounted for in this paper. In the discussion section of the research paper, which I recommend you read, the authors state:
“Other predictors of future episodes of LBP after an initial episode include the severity of pain during the initial episode, alterations in central nervous system structure and function, and depression and psychological distress. These factors were not investigated in any of the studies reviewed and should be included in future studies of golf-related LBP.”
Despite the logical argument that higher swing speeds generate more forces within the spine, there is lacking evidence that specific biomechanical tendencies cause low back pain in golfers. Although it is easy to assume that a golfer like Bryson Dechambeau would be more likely to experience low back pain compared to a golfer with a more tame swing, this does not appear to be true.
We like to think that we can prevent injury by avoiding certain positions, and in some cases that is possible. Other times, however, the biomechanics of a movement don’t translate to things like injury or tissue damage. On top of that, someone may have real tissue damage, but never know it because they experience no symptoms. 30% of asymptomatic 20 year olds have a bulging disc, which increases to 84% for those who are 80 years of age. Other times, a person with real pain may have an image taken of their spine, and there are no noticeable lesions. This highlights the discrepancy between anatomy/biomechanics of the human body and the lived experience of the person in front of you.
Oftentimes, injuries related to sports are a result of doing too much, too soon. An example I like to use is running. If you got off the couch and went for a 10 mile run without any training, you would probably get some aches and pains. Maybe it would be enough tissue irritation to cause something like Achilles or patellar tendinopathy. However, if you did a walk/run program over the course of a few months and slowly progressed toward the 10-mile goal, you would likely be able to complete that run with no issues. I would guess that something similar happens in golfers; many of them are sedentary during the winter, then their body’s tissue gets angry with their first few rounds of the year, as the tissue is not adapted to the demands that golfing 18 holes requires.
What can you do about it?
If you are one of the unlucky ones to experience low back pain from golf, fear not. While we cannot control our aging, we can do our best to eat healthy, exercise, and get good sleep. Taking care of your physical and mental health is a fantastic place to start to prevent injuries or heal from one you have already sustained. If you do find yourself with some back soreness or muscular tightness, there are a number of things you can do to feel better and get rid of it.
As a disclaimer, this is not intended to be medical advice for any particular issue, only a rough guideline for general muscle soreness. If you suspect an injury, consult a medical professional.
When we have back pain, our muscles can become tight and painful. Doing some soft tissue mobilization with a device like the QL claw can decrease pain in the short term, allowing you to move better and add in some stretches and core exercises, which can improve your ability to move while reducing your pain. The main goal should be to increase the capacities of your tissues to handle the loads of any repetitive activity, such as golfing or running.
Sources:
[1] https://www.ngf.org/the-clubhouse/golf-industry-research/
[2] Cole MH, Grimshaw PN. The Biomechanics of the Modern Golf Swing: Implications for Lower Back Injuries. Sports Med. 2016 Mar;46(3):339-51. doi: 10.1007/s40279-015-0429-1. PMID: 26604102.
[3] Chiodo AE, Bhat SN, Van Harrison R, et al. Low Back Pain [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2020 Nov. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572334/
[4] Smith JA, Hawkins A, Grant-Beuttler M, Beuttler R, Lee SP. Risk Factors Associated With Low Back Pain in Golfers: A Systematic Review and Meta-analysis. Sports Health. 2018 Nov/Dec;10(6):538-546. doi: 10.1177/1941738118795425. Epub 2018 Aug 21. PMID: 30130164; PMCID: PMC6204638.
[5] https://theultimategolfschool.net/x-factor-explained/