**22. Other common leading wrist pathologies in a golfing population**

#### **22.1 The triangular fibrocartilage injury of the wrist**

The triangular fibrocartilage complex (TFCC) (**Figure 16**) is a load-bearing structure between the lunate, triquetrum, and ulnar head. It is a hammock-like structure made up of cartilage and ligaments. It stabilises the bones in the wrist, acts as a shock absorber and enables smooth movements. Forced ulnar deviation and positive ulnar variation are associated with injuries to the TFCC. A "weak" golf grip and swing biomechanics abnormalities makes injury to this structure more common.

The TFCC complex is prone to degeneration and wear-and-tear injuries. Injury occurs when compressive loads are placed on the TFCC during marked ulnar deviation. This occurs in the golf swing when the radial deviation of the wrist at the top

**Figure 16.** *Triangular fibrocartilage (TFCC).*

of the back swing converts into ulnar deviation under significant force at impact. The triangular fibrocartilage disc attachment on the radial side is to hyaline cartilage. This makes the area vulnerable to injury as it is weaker when compared to the ulnar side whose attachment is bony.

Injury to the TFCC can lead to pain, weakness and instability. Patients with TFCC injury will present with ulnar-sided wrist pain that may present with clicking or point tenderness between the pisiform and the ulnar head.

The TFCC can be strained or torn from over-swinging or from "hitting down on the ball". Hitting out of heavy rough or on hard practice matts are also extrinsic culprits in the development of this injury in the golfing population.

Diagnosis is confirmed by assessment of the sixth extensor compartment. At this location, the TFCC is examined in combination with the ECU tendon. The ECU relies on the TFCC for movement and hence both structures can be injured in combination.

Radiology may reveal avulsion of ulnar styloid, and ulnar variance in cases of the TFCC injury. High-resolution dynamic ultrasound (US) has emerged as a useful and valid tool for the diagnosis of this disorders [36–38].

#### **22.2 Hook of the hamate**

The hamate bone (**Figure 17**) is one of the largest carpal bones and is located on the ulnar side of the palm of the hand and forms part of the distal carpal row. It has a protrusion called the "hook of hamate" which with the pisiform bones form the bony boundaries of Guyon's Canal through which the ulnar nerve enters the wrist joint. Hook fractures can occur from a direct injury to the bone or from an indirect blow that occurs most commonly in sports [42].

In golf, most hook of hamate fractures occur because of the position of the golf club resting on the hook when hitting "down" on the ball, when it is buried in rough or embedded in a divot. These injuries are also common when hitting buckets of balls from a mat at the driving range. Many of the older ranges are built on concrete

**Figure 17.** *Hook of the hamate bone.*

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

and injuries occur when the club head stops abruptly on the matt covering the concrete. The force of the impact is conducted through the club shaft and grip into the base of the hand and hamate bone, resulting in injury. That force is transmitted directly to the wrist and can cause a fracture of the hook of the hamate. These injuries occur more commonly in the following wrist [right hand in a right-handed golfer]. While fractures are rare and underreported, they are also frequently misdiagnosed as the initial trauma may seem trivial and present with a working diagnosis of a wrist sprain. Palpation of the hamate with or without ulnar nerve symptoms are cardinal findings. Plain radiology will confirm the diagnosis and conservative treatment such as rest and splinting usually resolves the problem.

### **22.3 Carpal tunnel syndrome [CTS]**

Carpal Tunnel Syndrome (**Figure 18**) is the entrapment of the median nerve and repetitive use of the hands and wrists seen in golf contribute to the development of CTS. Repetitive activity such as golf swinging and practicing can result in flexor tenosynovitis as one or more of the 9 flexor tendons that travel through the Carpal Tunnel in the company of the median nerve become inflamed. Inflammation in the affected tendons in the wrist result in swelling of the sheath. This fluid will compromise the function of the nerve resulting in the symptoms of distal median neuropathy.

Golfers can be difficult to convince that the tingling fingers, numb hands or aching thumb or wrist pain is a result of Carpal Tunnel Syndrome. CTS is considered a disorder that only affects those who do intense repetitive activities all day long at work [43, 44], such as block laying, hairdressing [26] or computer keyboard work. However, in modern society golf driving ranges and facilities are readily available and frequently recreational golfers work harder on their golf than many other vocational pursuits.

Sports, pastimes and hobbies can play a major role in contributing to this repetitive strain induced hand and wrist condition. The repetitive activity causes inflammation to some of the 9 flexor tendons that travel through the Carpal Tunnel. This inflammation results in swelling which ultimately affects the function of the median nerve. CTS diagnosis is made by a combination of electrodiagnostic nerve conduction studies and ultrasound examinations. Treatment of this common condition which affects between 5% and 21% of the population [43–49] involves

**Figure 18.** *Carpal tunnel syndrome.*

**Figure 19.** *Guyon's canal syndrome.*

a combination of treatments including splinting the wrist, injection therapy and surgery. In the golfer, correction of golf biomechanics and golf club customization are helpful in preventing reoccurrence.

#### **22.4 Guyon's canal syndrome**

Guyon's canal syndrome (**Figure 19**) is a condition where there is compression and irritation of the ulnar nerve at the wrist. The ulnar nerve is responsible for strength and sensation on the little finger's side of the fourth finger and the entire fifth finger. Golfers with this condition may present with pain at the base of the wrist, loss of finger function and grip pressure as well as sensory alteration in the 4th and 5th fingers.

The hand may become clumsy when the muscles controlled by the ulnar nerve become weak. Weakness can affect the small muscles in the palm of the hand and the muscle that pulls the thumb into the palm.

Golfers are prone to irritation at Guyon's canal from local trauma to the nerve associated with an improper golf grip and trauma from the butt of the golf club impacting at the base of the wrist [50].

Hard playing surfaces and hitting down on the ball are risk factors.

Diagnosis is made by Electrodiagnostic testing of the distal ulnar nerve. Ultrasound is also used to out rule other space occupying lesions such as a ganglion cyst or schwannoma.

This syndrome is much less common than carpal tunnel syndrome (CTS), yet both conditions can occur at the same time. The numbness by Guyon's syndrome usually spares the thumb, index and long fingers.
