**19. Wrist injuries in golf**

Wrist injuries are common [25–27] and particularly prevalent in elite golfers [28, 64]. Golfers who sustain injuries to their wrist regularly fail to rest after practice sessions and do not allow adequate time for soft tissue recovery and adaptation after a heavy practice session. It is not uncommon for an elite golfer to hit balls every day. Enthusiastic amateurs can be seen hitting "buckets" of balls in an effort to groove a repetitive swing. A standard bucket of balls in a driving range contains 50 to 60 balls when a round of golf rarely exceeds 40 full shots. This simple training error often under pins wrist injuries.

These wrist injuries are often extended and exacerbated by "playing through the pain" which must always be discouraged. This behaviour is most prevalent in men who outweigh injuries in female golfers by 2 to 1 [12, 27]. This area is also more frequently affected in the professional ranks as the golf swing is a means of income, much in the same way as other manual occupations such as painters and decorators [29] suffer from overuse injuries to the upper limb (11). In a 30-person cohort 43%

of hairdressers reported overuse injury symptoms to hands and wrists form their work activity [30].

In golf it is almost impossible to consistently hit a golf ball with an injury to the wrist or hand which is the second most common site for golf injuries and a result of impacting the ball incorrectly due to poor swing mechanics [8–10].

Patterns of injury differ based on level of play and time spent playing or practicing golf. Among golf professionals, the hand/wrist is the most commonly injured upper extremity structure. The elbow is more commonly injured than the wrist in amateur golfers [31].

## **20. Common leading wrist pathologies in a golfing population**

The medial aspect of the leading wrist in a golfer is particularly prone to injury due to the forces and stress applied to this location during the modern golf swing. The most common structure to be injured is the Extensor Carpi Ulnaris tendon and its tendon sheath and sub-sheath.

Extensor Carpi Ulnaris (ECU) tendinitis & tendinosis. ECU tendon Subluxation. Triangular Fibro-cartilage injury. Hook of Hamate injury. Guyon's Canal Syndrome. Carpal Tunnel Syndrome. Dupuytren's contracture. Flexor Carpi Ulnaris tendon. Proximal entrapment of the ulnar nerve. Proximal entrapment of the median nerve.

#### **20.1 Extensor carpi ulnaris tendon Injuries in golfers**

The extensor carpi ulnaris tendon (**Figure 10**) originates from the lateral epicondyle of the humerus and the dorsal surface of the ulna, passes through the groove dorsally at the ulnar head within a fibro-osseous tunnel of extensor retinaculum in the 6th compartment (**Figure 11**). It has its own tendon sub-sheath for its stabilisation there and inserts on the base of the 5th metacarpal medially angled to its position in the groove of ulnar head. It acts to adduct (or ulnar deviate) and extend the wrist joint.

The Extensor Carpi Ulnaris tendon (ECU) is particularly vulnerable to injury in the golfing population because of the complex nature of the golf swing. During the golf swing the leading wrist goes through a complex motion involving ulnar and radial deviation i.e. extension and flexion and pronation and supination. These manoeuvres send forces through the wrist joint culminating with the impact of club on ball (**Figure 1**). The anatomical location of the ECU tendon in the 6th extensor compartment (**Figure 12**) held in a tendon sheath makes it liable to injury due to the excessive tensile loading and subsequent breakdown of the loaded tendon [32, 33]. ECU Tendinopathies, and tendon injuries account for significant time away from sport and lost time in practice and competition [9–11, 34, 35].

#### *20.1.1 Types of ECU tendon injury*

ECU tendon injuries come in many varieties and severities but can be simply divided in to 3 major categories of injury.

*Leading Wrist Injuries in a Golfing Population. Golf Swing Biomechanics a Significant Cause… DOI: http://dx.doi.org/10.5772/intechopen.96979*

**Figure 10.** *ECU muscle and tendon origin and insertion.*

#### **Figure 11.**

*The double pendulum effect of the golf swing. The first pendulum is the arm acting around the pivot of the shoulder joint and torso. The second pendulum is the golf club acting around the wrist joint.*

There are 3 types of injury that occur to the ECU tendon in the golfing population. Each is associated with overuse caused by excessive play and practice accompanied by poor swing technique [36].


#### **Figure 12.**

*ECU tendon, tendon sheath and sub sheath in the 6th extensor compartment of the wrist.*

Injury to the ECU tendon in the leading wrist of a golfer is common due to the forceful return of the ball as the leading wrist travels from a radial deviated position at the top of the backswing to an ulnar deviated position at impact with the second carpal row transitioning into a supinate position. Injury and subluxation of the ECU tendon are exacerbated by ulnar deviation and supination [37], which is the classical position of the leading wrist at impact during a golf swing. Hence the frequency of this injury in golfers.

#### *20.1.1.1 ECU tendinopathy*

Tendinopathy or tendinosis refers to the breakdown of collagen in a tendon. Tendinopathy is often the long consequence of long-term inflammation caused by tendinitis. This causes burning pain in addition to reduced flexibility and range of motion. The collagen loss being a function of tenocyte malfunction secondary to chronic and reoccurring inflammation and injury. ECU tendinopathy occurs over time due to repetitive insults. The Tendinopathy is a pathological adaptive response resulting in degeneration due to the tendon's collagen loss in response to chronic overuse. Loss of function as well as pain on activity are cardinal complaints.

## *20.1.1.2 ECU tendinitis*

Tendinitis is the inflammation of the tendon and results from micro-tears that happen when the musculotendinous unit is acutely overloaded with a tensile force that is too heavy and/or too sudden. ECU tenosynovitis can occur when the extensor retinaculum tears. It can result in mechanical friction between the ECU tendon and the ulnar groove [36, 37]. It usually starts as tendon irritation manifesting as pain and can progress to friction between the tendon and the ulnar grove. In the golf swing the ECU is irritated by the motion to and from ulnar and radial deviation with the wrist in a supinated position. Symptoms include wrist pain and loss of grip strength.

#### *20.1.1.3 ECU tendon subluxation*

If the tendon sheath and sub sheath rupture or stretch, the ECU tendon can then migrate to the medial or ulnar side of the wrist. This is caused by a rupture on the

*Leading Wrist Injuries in a Golfing Population. Golf Swing Biomechanics a Significant Cause… DOI: http://dx.doi.org/10.5772/intechopen.96979*

#### **Figure 13.**

*Axial MR and graphic image of split ECU tendon tear with partial rupture of sub-sheath with medial subluxation of the tendon.*

**Figure 14.** *The 3 types of ECU sub sheath injury resulting in tendon subluxation.*

**Figure 15.** *Coronal MR image showing ECU tear and tenosynovitis.*

ulnar or radial side of the tendon sub-sheath, or if the sub-sheath is stretched due to stripping of the periosteum (**Figure 13**). Each type results in subluxation and relocation producing a snapping sensation at the wrist during the golf swing. There are 3 types of ECU tendon sub-sheath injury.

Type 1 (**Figure 14**) rupture occurs on the lateral side of the sub sheath. The tendon subluxes through the radial side of the sheath and returns to rest on the ulnar grove on top of the remaining sheath.

Type 2 (**Figure 14**) rupture occurs on the medial side resulting in a tendon subluxing in an ulnar direction before returning to the ulnar groove without resting on top of the sheath.

Type3 (**Figure 14**) subluxation occurs if the ECU sheath does not rupture but the force causes ulnar periosteum stripping: The ECU sheath pulls the periosteum off the ulna on the ulnar side and forms a false pouch into which the tendon dislocates before relocating back onto the ulnar groove (**Figure 15**).
