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PAGE 7 Maximising Performance in Golf

PAGE 20 Lessons in Golf Medicine from Chief Medical Officer of the European Tour and Ryder Cup Team, Dr Roger Hawkes

PAGE 23 Exploring the Relationship between Golf and Health

EDITORS’ NOTE Elite sports medicine has the power to support filter of innovations down to serve the health needs of the wider population. In recent years, the FIFA 11+ warm-up in football has shown huge potential to prevent injuries across all levels of football, and it is not unreasonable to conclude that this may lead to savings within our health service. It comes as no surprise that the 11+ has informed programs in other sports, such as rugby, where the addition of a neck strengthening element aims to reduce the number of concussions in the amateur game. Less injuries and concussions means increased opportunities for people to accrue the benefits of physical activity while playing their favourite sports. These are admirable advances in sports medicine, yet the elephant in the room nags; what about our middle-aged to elderly population (where participation in rugby and football drops off significantly)? This cohort are increasingly at risk from the perils of a sedentary lifestyle such as Type 2 Diabetes, Ischaemic Heart Disease, Hypertension and countless other chronic diseases. Emerging evidence seems to suggest golf can be part of the solution, providing moderate intensity physical activity, which can be gained across the lifespan. In light of this, it gives us great pleasure to welcome Dr Andrew Murray as guest editor of the 5th edition of the USEMS eMagazine. As well as working as the Deputy Chief Medical Officer on The European Tour, Andrew’s PhD is looking at the relationships between golf and health, working with the World Golf Foundation. We look forward to highlighting the encouraging work carried out to date throughout this edition. Additionally, we will also delve deeply into what life is like managing the health of the world’s best golfers. Dr Roger Hawkes, longstanding Chief Medical Officer of The European Tour, provides a fascinating insight into the challenges faced, while there are excellent contributions from the European Tour Performance Institute (ETPI) on common pathologies encountered in elite golfers. And lots more, besides. It’s the 5th edition of the eMag, and for the fifth time we find ourselves saying that “this is the best edition to date”, but we truly believe this is. As ever, we welcome your feedback and would appreciate if you could share this resource far and wide. Yours in Golf, Dr Sean Carmody (Co-Editor), Dr Fadi Hassan (Co-Editor) Dr Andrew Murray (Guest Editor, 5th Edition) 1

contents FEATURED



03 Shoulder Injuries in Golf

08 Maximising Performance

15 Nutrition for Golf

11 Golf and the Lower Back

09 Head Injuries and Return

20 Interview with Dr Roger

23 Golf and Health - Article

17 Study on Physical

30 Interview with Michele

by Dr Roger Hawkes and Professor Lennard Funk by Nigel Tilley

and Infographic

2 USEMS / JULY 2017

in Golf

to Sport

Activity in Supporters of Professional Sports




SHOULDER INJURIES IN GOLF Dr Roger Hawkes (Chief Medical Officer of the European Tour) and Professor Lennard Funk (Consultant Shoulder Surgeon) outline the common shoulder pathologies encountered in golfers. Golf is a unique sport with regards to the shoulders in that each shoulder has to do a very specific and very opposite manoeuvre in swinging the golf club. The leading shoulder is forced and stretched into an extreme adducted position at the top of the backswing and the non leading shoulder into an abducted externally rotated position.  This leads to very different pathologies in each shoulder.   

horizontal and vertical extremes has been shown to be a mechanism for shoulder injury particularly with the number of repetitions during play and practice (Mitchell et al. J Orth Sports Physical Therapy). Shoulder injuries are also second to spinal injuries for increasing number of rounds and balls hit per week, with a higher number of shoulder injuries in golfer’s who play four or more rounds per week or hit more than 200 hundred balls per week.

The leading shoulder is prone to: 1 Subacromial impingement. 2 AC joint pain. 3 Posterior instability. 4 Rotator cuff tears. The non leading shoulder is prone to: 1 Subacromial impingement. 2 SLAP tears (superior labral anteroposterior lesion). 3 Anterior instability. 4 Rotator cuff tears. In golf, although not being considered an overhead sport, 30% of the swing is spent vertically elevated above 90°. The combination of 3

Over the years the swing has changed, with an increased torsion required by the whole trunk and shoulders in creating a powerful drive shot. This is equivalent to releasing a coiled spring. Therefore modern day golfers tend to be hyperflexible with extreme rotation between the pelvis and shoulders achieved during the swing.  This is known as the X factor and a high X factor of 70° is thought to be advantageous for a powerful drive.  

In addition to the muscular effects above the extreme adducted position coupled with underlying joint hyerlaxity leads to excessive posterior capsular stretch and a subclinical posterior instability of the leading shoulder. This can progress to posterior labral tears as well as antero-superior internal impingement and subacromial impingement as the greater tuberosity passes very close to the anterosuperior labrum and under the acromion.   The excess posterior capsular laxity can be assessed by testing internal and external rotation in 90° abduction. One may find excess internal rotation on the leading shoulder compared to the nonleading shoulder.

In this position the leading shoulder is in extreme adduction. This tends to lead to a shortening of the anterior shoulder structures with protraction of the shoulder. Pectoralis minor is thought to be the main protractor.

In the leading shoulder the pectoralis minor muscle becomes tight and shortened, whilst the rhomboid are stretched and lengthened Measuring the distance from the medial border of scapula to the thoracic spine. Note the larger distance on the leading shoulder side (left)

There is thought to be an equivalent lengthening/ stretching of the posterior scapular muscles, particularly the rhomboids. This can be seen clinically by measuring the distance between the thoracic spine and the medial border of the scapular and comparing this to the same distance in the non leading shoulder.  In extreme cases this distance will be increased showing lengthening of the rhomboids and protraction of the shoulder. Clinically a scapular dysrhythmia can also be seen with the shoulder protracting more through abduction and flexion compared to the opposite side.

In addition to the muscular effects above the extreme adducted position coupled with underlying joint hyerlaxity leads to excessive posterior capsular stretch and a subclinical 4

posterior instability of the leading shoulder. This can progress to posterior labral tears as well as antero-superior internal impingement and subacromial impingement as the greater tuberosity passes very close to the anterosuperior labrum and under the acromion. The excess posterior capsular laxity can be assessed by testing internal and external rotation in 90° abduction. One may find excess internal rotation on the leading shoulder compared to the non leading shoulder.

The repetitive adducted position can also cause subacromial impingement and AC joint pain. This particularly occurs with older golfer’s who may have some pre-existing AC joint degeneration.

Internal impingement on the non-leading shoulder exists between infraspinatus and the glenohumeral joint, due to the extreme external rotation of the golf swing.

Posterior capsular stretch and posterior labral injury in the leading shoulder

Diagnosis A diagnostic algorithm can be applied to both the young and the older golfer’s with a cut off age of approximately 35 years. The younger golfer’s are those that are more lax and more prone to sub clinical posterior instability, labral pathologies and secondary subacromial impingement.   They may also progress to developing partial thickness rotator cuff tears. Assessment of internal rotation in the golfer. Note the excess internal rotation in the leading shoulder (left shoulder) compared to the non-leading shoulder (right shoulder)

The specific clinical findings and examination should be to assess: 1 Hyperlaxity with a Beighton score. 5

2 Painful clicking on circumduction of the shoulder.

from underlying osteophytes from the acromion, from the AC joint and assessing the rotator cuff as well as possible large osteochondral lesions.

3 Excess internal rotation in abduction compared to the non leading shoulder. 4 Positive O’Brien’s test with both pain and weakness particularly posteriorly as the humeral head translates posteriorly in the adducted internally rotated position. 5 Subacromial impingement tests including Hawkins’ and Neer’s sign. In the older player clinical examination should be directed towards:


1 Impingement tests: Hawkin's and Neer’s sign.

In the young golfer with a normal MR arthrogram specialist rehabilitation would be the main treatment. This should include scapular correction exercises, balancing the scapular protractors and retractors as well as sports specific rehabilitation.   Core stability and working on the kinetic chain particularly for golf is essential.

2 Acromioclavicular joint tests: direct tenderness, Scarf test and Paxinos test, rotator cuff tests should also be performed.

Should the MR arthrogram confirm a labral tear arthroscopic repair would be appropriate. However significant tightening of the posterior capsule is not recommended as this will significantly delay or restrict a return to golf. In the older golfer the standard treatments for impingement, AC joint arthritis or rotator cuff pathology as found would apply.

Investigations In the young patients the gold standard investigation is an MR arthrogram as this should give a better idea of the capsular laxity and labral pathologies. In the older golfer an x ray would be beneficial for AC joint pathology as well as possible impingement signs. Ultrasound scan is useful for impingement and assessing the rotator cuff and MRI scan may be useful to look for impingement 6

Return to golf rehab post operative and post injury rehabilitation can be directed to sports specific return to golf rehab from a very early stage.

References & Bibliography: 1 Kim Mitchell, Scott A. Banks, Hiroyuki Sugaya. Shoulder Motions During the Golf Swing in Male Amateur Golfers. J Orthop Sports Phys Ther. 2003; 33(4):196-203.

At three to four weeks following surgery or standard rehabs one handed putting with the affected arm can be started, putting through the lane by lining up shots using string instead of clubs can be done.

2 Gosheger G, Liem D, Ludwig K, Greshake O, Winkelmann W. Injuries and overuse syndromes in golf. Am J Sports Med. 2003 MayJun;31(3):438-43.

The swing can be recaptured and very early on by performing simple body twisting exercises reproducing the swing motions and working on core stability and kinetic chain in this way. The sport can be brought into the therapists gym by using therabands to reproduce the golf swing.  

3 Smoljanovic T, Bojanic I, Hannafin JA, Hren D, Delimar D, Pecina M. Traumatic and overuse injuries among international elite junior rowers. Am J Sports Med. 2009 Jun;37(6):1193-9. Epub 2009 Mar 19. 4 Hovis WD, Dean MT, Mallon WJ, Hawkins RJ. Posterior instability of the shoulder with secondary impingement in elite golfers. Am J Sports Med. 2002 Nov-Dec;30(6):886-90.

Short game strokes and ball hitting can start generally by the end of the second month with increased shoulder stretching particularly working on any tightness either anteriorly or posteriorly to return the normal golfing motion in the shoulder joint. Golf drills can generally start at the second or third month and the player return to the pre-teaching pro at that stage under guidance and with good communication from the physiotherapist and surgeon.  

5 Kim DH, Millett PJ, Warner JJ, Jobe FW. Shoulder injuries in golf. Am J Sports Med. 2004 Jul-Aug;32(5):1324-30.

There should be good communication between the patient’s surgeon, physiotherapist and the teaching pro at all stages.

SUMMARY Shoulder injuries in golf are common.   They are unique to each shoulder and also to golf.   The awareness of sub clinical posterior instability in the non leading shoulder is increasing and a good multi-disciplinary treatment at all stages is the ideal management for an early return to golf.



A Study of Head Injury Advice on Return To Sport in Accident and Emergency Rishi Dhand1 2, David Khamoo1, David Eastwood1 1University Hospital of North Durham, 2Sunderland Royal Hospital

Part B: Retrospective analysis of the notes of all A+E patients who attended University Hospital of North Durham (UHND) over a 6 month period.


• •

Return to play (RTP) post head injury is a controversial yet important topic.

Inclusion criteria:

• • •

Repeated head injuries have been linked to short and long-term neurological sequelae such as Post Concussion Syndrome1, Second Impact Syndrome2, Chronic Traumatic Encephalopathy (CTE)3 and in some cases, fatality.

Patients aged 18-50 Seen by a healthcare professional Discharged Home

NICE Guidance states there should be printed advice given to patients for returning to sports4. Elite and non-elite athletes should follow a graduated RTP protocol after head injury.

A total of 326 patients were identified and analysed in Part B.

There is currently no definite time period that a player must be withheld from playing following concussion5. Although some professional bodies recommend at least 14 days of rest.

Part A


Number of trusts with no routine information on their standard head injury information cards for RTP after a head injury= 6 (75%) (Figure 1).

Aims To assess whether RTP advice was given to patients being discharged home from Accident and Emergency (A+E) after a head injury.




Part A: Standard head injury advice cards for all 8 trusts in the Northern Deanery were collected and analysed for advice on return to sport.

Yes No

Figure 1- Did trusts in the Northern Deanery provide routine information for RTP on standard head injury information cards?



Part B

Number of patients given advice on when to return to sport= 2 (0.6%) (Figure 2).

The analysis was based on what was documented. Advice may have been given and not documented.

1 patient advised “no contact sport for 6 weeks”
 1 patient advised “to rest for the rest of the week”

Trusts have a head injury card in place to give to patients so may not offer further specific advice.



Yes No

Thanks to all 8 trusts in the Northern deanery for providing their head injury information advice cards.

99.4% Figure 2- Was there RTP advice in analysis of the notes for patients discharged with head injury at UHND?


• •

Number of patients attending with head injury sustained whilst playing sport= 49 (15%)

1. (2016). Concussion - Complications - NHS Choices. [online] Available at:

Number of patients who displayed symptom(s) suggestive of concussion= 243 (75%) ns.aspx 2 McCrory,P. et al (2012), Second Impact Syndrome or Cerebral Swelling after Sporting Head Injury. Current Sports Medicine Reports, 11(1), pp.21-23


3. McKee, A. et al (2009), Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy After Repetitive Head Injury. J Neuropathol Exp Neurol, 68 (7), pp. 709-735

The results indicate that we may be neglecting return to play advice for our patients attending A+E with a head injury.

4. (2014). Head injury: assessment and early management | 1-Recommendations | Guidance and guidelines | NICE. [online] Available at:

• •

A+E departments should be encouraged to provide advice to patients on return to sport. Results show that there should be an emphasis on greater education for for both healthcare professionals and patients.

5. McCrory, al (2013). Consensus Statement on Concussion in Sport—the 4th International Conference on Concussion in Sport Held in Zurich, November 2012.Clinical Journal of Sport Medicine, 23(2), pp. 89-117.

Further data is needed across a number of A +E departments. The recommended rest prior to RTP and the definite long-term effects of repeated head still requires further research.


GOLF AND THE LOWER BACK ARTICLE BY NIGEL TILLEY Nigel Tilley – a Consultant Physiotherapist on The European Tour – examines lower back injuries in golf and how physiotherapy can help.

We know that lower back injuries are the most common injuries in golfers, accounting for roughly 30 per cent of physical complaints involved with playing the sport. The average golf swing will place high downward compression, side to side bending and back to front shearing forces through the lumbar spine. The spine is poorly adapted to tolerate these types of stresses. Loads of eight times body weight have been shown to go through the lumbar spines structures during the golf swing. Poor technique can increase these stresses further.

Picture this: It’s a cold Saturday morning and you’re on the first tee at your local golf club for the morning medal. You got up late and rushed to the tee with just a few moments to spare after a 30 minute drive to the course. You’ve had no warm up, you haven’t played golf for more than a week and the last time you did any type of exercise was many moons ago. Does this sound like you?

However, with regular conditioning, improvement in technique, warm ups and structured practice, the improvements in golfers' performance and reduction of injuries can be significant. Your physiotherapist can help you with this as well as provide you with effective treatment should you suffer with any injuries.

Does this sound like the ideal way to prepare your body for the forces and stresses about to go through it when swinging a club aggressively and hitting a golf ball many times? Do you think this is how professional golfers would prepare for a round? Do you think you will play your best? Do you think you will wake up tomorrow feeling fresh and with no aches and pains? Obviously, the answer to all of those is most likely, no. 11

and investigations to drive the diagnosis and management of low back pain. We aim to use sound clinical assessment and reasoning and a holistic look at the individual as they present to us.

Non-specific low back pain There are a large range of conditions involving many structures that can be injured or develop pathologies in the lower back. These can cause pain among other symptoms and affect range of movement. The small joints (facet joints), connective tissues (ligaments, muscles, tendons), discs, and nervous tissues may be involved.  Acute conditions such as sprains and strains and the normal effects of ageing cause these structures to wear and reduce their ability to tolerate the high forces and ranges of movement that are required in the golf swing.  However, the soreness and stiffness that people often present with is called 'non specific' as it is not usually clear which structure is causing the problem and/or pain.

Poor technique and lack of flexibility in the mid spine and hips are all linked with increased incidence of lower back pain. Often it presents as an aching and discomfort on moving into certain positions and doing certain activities, but can come on after a sudden movement and/or activity or for less obvious reasons. The modern golf swing requires a player to be able to generate, control and slow huge forces during the execution of a golf swing. The problems we often see involve a combination of poor practice routines, poor technique, lack of conditioning, lack of flexibility at the spine and other areas of the body and lack of ability to cope with the huge forces the golf swing puts though the body and the structures.

How Does physiotherapy treat this type of condition? Physiotherapists are highly trained professionals and will be able to assess you fully and identify non-specific lower back pain (NSLBP) from potentially more serious lower back pathologies.

There is a poor correlation between pathology of musculoskeletal structures as seen on scans such as MRI’s, CT’s and X-rays and the symptoms and pain people report and present with. In fact, as we age it is very normal for the majority of us to start to have changes to many of these structures.

Trying to remain active and avoiding extended periods of rest is important in people with NSLBP. Whilst it may be a good idea in the very initial s t a g e s of t h e p ro b l e m to re d u ce o r avoid significant movements or activities that aggravate the symptoms, it is a good idea to keep mobile and try to do stretches and exercises that relieve the symptoms and promote normal movement.

Evidence has shown that the vast majority of people have no pain or symptoms despite having changes to the structures seen with imaging. It is, therefore, critical that we do not rely on scans 12

These are often specific to each individual and your physiotherapist will discuss the best options for you. Often in the initial phases, the use of heat via hot packs and baths can help as well as manual therapy treatments, soft tissue massage, TENS and advice on the best ways to lift, bend, sit and move in out of the car and bed.

your body for the activity it is about to do. A warm up should last 10-15 minutes and involve increasing heart rate & blood flow, activating the muscles involved in the swing and spinal control, and stimulating the bodies motor control mechanisms. This will help prepare you for playing golf and help reduce your risk of injury.

The aim of physiotherapy is to promote self-management, help you understand your pain better and to help develop your physical conditioning. It has been found that physical de-conditioning plays a role in acute NSLBP. This can be general fitness conditioning as well as specific exercise, stretches and programmes that aim to address limitations in certain parts of the body and prepare the body to tolerate the requirements and forces of the golf swing.

The ETPI aims to ‘make golfers stronger, more robust and more stable’. This should be the goal of your training and conditioning programme. Reviewing your practice and play habits can also help identify and direct your golfing activity more appropriately to reduce the effects of overload. Article kindly provided by The European Tour Performance Institute. For more great resources visit

We know that in golfers, technique faults and a lack of flexibility and/or movement in the hip and thoracic (mid) spine are linked to lower back pain. Physiotherapy can help with NSLBP by restoring movement to these areas and providing golf specific stretches and exercises that can help to improve technique and promote better conditioning of the body for playing golf. Well taught and well performed strength and conditioning exercises working on compound movements (multi joint/whole body) and developing strength and control in the lower limbs, trunk and upper body are fundamental components of a professional golfer's training. These can be extremely effective techniques to help those with NSLBP control and eliminate their s y m pto m s w h i l e i m p rov i n g t h e i r g o l f performance. It is important that you warm up properly each and every time before you play golf to prepare


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NUTRITION FOR GOLF ARTICLE BY DAVID DUNNE | PERFORMANCE NUTRITIONIST Golf is, without doubt, one of the most exciting opportunities in the world of performance science in 2017. However, despite these high stakes there has been very little research done to date in elite golf. This forces us as a practitioner group to extrapolate ideas from other areas of research and trial them with the players we work with as we refine and optimise our strategies and learn from the players, coaches and caddies until the research catches up. I’m pretty fortunate to have a younger brother on the European Tour who has fast tracked my practitioner learning curve in golf and helped build up some practice based evidence which hopefully over the next few years can be trialled and tested to eventually translate into evidenced based practice. Until such a time, I hope the below provides an insight into some considerations for performance nutritionists working with golfers or even some food for thought (apologies for the pun) for the Tour professionals themselves.

we looking for? Well when we look at the demands of golf a round generally takes approximately 4 hours, top this up with 60-120 minutes of prep time (warm up, range, putting green, conversations with caddy, etc) and we are looking at about a 5-6 hour shift. During this 5-6 hour shift mental focus, stable energy levels and adequate hydration are going to be key, as one poor decision or energy dip can ruin your card and separate the winners from the also-rans. As a result the pre round meal should be finished approximately 90 minutes before the round to give the body time to digest the food and the player time to prepare. The meal itself should contain some high fibre low GI carbohydrates, such as oats, to provide a sustained release of energy over the coming hours. This portion of carbohydrates should be complemented with a source of high quality protein, such as greek yoghurt or eggs, to not only supply the muscles with amino acids to support muscle maintenance and function but also to aid the production of neurotransmitters to improve mental focus and induce satiety. This base of protein and carbs should then be finished off with some high quality dietary sources of fat to provide some low intensity fuel, e.g. nuts, seeds, avocado, etc as well as some fruits and/or vegetables to bump up the micronutrient content of the meal. A simple example of this for a 9am tee time would be a bowl of nutty muesli topped with banana and fresh berries coupled with a 3 egg omelette and a large glass of water

Pre Round Fuelling Golfers are faced with 3 different fuelling scenarios on a day to day basis. They are either out early (which often means a 5am start!), mid morning, or in the early afternoon. Despite these timings changing, which may impact on meal timings and portion size, the underlying principles of how to fuel the round don’t. Ok so what are 15

at 6.45am. For a 2pm tee time, a baked salmon fillet with a sweet potato and feta salad would also be a good example.

Nutrition for Recovery/Sleep Post round the shift focuses to recover for the following day’s play. Again this meal should contain some quality protein to aid muscle repair and maintenance however, unlike most sports there is no need to feed high volumes of carbohydrates to refuel, a moderate potion accompanied with some tasty vegetables will do. For example, a nice lean steak with some mash potato and pan fried vegetables would fit nicely, as would a tasty teriyaki chicken stir-fry with some additional vegetables. This meal is generally the easiest for most players to get right. This meal should be followed up with a night-time snack, again to support recovery but also to enhance sleep, e.g. greek yoghurt with tart cherry mixed through.

On Course Nutrition The goal on the course is exactly the same, optimise mental focus, keep stable energy levels and remain hydrated. As a result on course snacks will follow a similar trend aiming to provide some low GI carbs, a moderate amount of protein and some high quality fats. To ensure a steady supply of energy as well as reducing symptoms of hunger it is best to spread 3-4 snacks out evenly over the round. Depending on the length of the course players may wish to eat on holes 5, 10 and 15 (particularly if it’s a shorter course) or on holes 4, 8, 12 and 16 (better suited to longer and/or slower rounds). These snacks can be prepared (in an ideal world) ahead of time by the player or one of their team or purchased for convenience. Some great examples of on course snacks that players/their team can prepare would be homemade protein bars, nut and seed “energy” balls, oat based banana bread. Speaking from experience some of these snacks can be prepared with no more equipment than a mixing bowl so could be an easy way to kill 10 minutes on a Monday and set you up for the week. However, preparing your own snacks is not always possible so picking up some nuts and seed tubes/bars, bananas, beef jerky and protein bars is also a good call.

Nutrition for Travel As the competition draws to a close on Sunday, most players make their way straight from the locker room to the airport as they head on to the next event. The tour schedule, in particular the European Tour, can be relentless and this high volume of flights, temporary time zones and often new/foreign cuisines all increase the risk of illness for the players and caddies. These at risk periods and shifting circadian rhythms should all be supported with appropriate performance planning to not only ensure the player and caddy acclimatise as soon as possible for the next tournament but also minimise the volume of days a player and his caddy may lose to illness.

What does need to stay more regular than the eating on course is the drinking! The best way to stay on top of this is to not only consume a few mouthfuls of fluid along with each snack, but also on each hole either as you are walking down the fairway or walking to the next tee box. You might find on hot days that you may need to do both! As for what’s in the bottle, it is best to drink water with additional electrolytes (a simple effervescent tablet will do - sugary sports drinks should be avoided). As a result the caddy should be equipped with 3-4 agreed on snacks for the player before leaving the locker room and 2 bottles of water and a tube of electrolytes to top up when needed during the round. The only time this may differ is on a Sunday, in which case you always bring more and are fully prepared to go down 19 if required!

I hope the above gives some insight and sparks some thoughts about how nutrition may impact on a golfer’s performance. With the lack of current evidence available it seems the next step is for the Tour to continue to innovate in performance nutrition research - then we can see how well the world’s best can really play. David Dunne is a performance nutritionist who has worked in elite rugby, football, cycling and Olympic sports. His brother, Paul Dunne, is a professional golfer on The European Tour.

@ thenutritionisr


A Study of the Physical Activity in supporters of Professional Sports Rishi Dhand12, Glen Rae123, Andy Richardson1
 1 Northumbria University, 2 Durham County Cricket Club, 3 Newcastle Racecourse


• • •

Physical inactivity has been identified as the fourth leading cause of global mortality according to the World Health Organisation.1 Regular moderate intensity physical activity and minimizing sedentary behaviour has significant benefits for health.2

• • •

The Department of Health (DOH) physical activity (PA) guidelines suggest that adults should achieve a weekly minimum of 150 minutes of moderate activity, 75 minutes of vigorous activity or a combination of the two. Adults should also partake in muscle strengthening (MS) exercise on at least two days per week.3

• Part 1- awareness and knowledge of PA guidelines • Part 2- amount of PA undertaken in an average week Supporters with health problems limiting moderate exercise were excluded from Part 2. Questionnaires were collected on the day. 277 supporters were analysed. Relevant data for incorrectly completed questionnaires was excluded and valid percentages were used.



• • •

A 2 part questionnaire was handed out to supporters aged over 18 attending a fixture at Durham County Cricket Club, Sunderland AFC, Newcastle Falcons RFC and Newcastle Racecourse.

• •

To assess Sports fans’ knowledge of PA and MS guidelines. To evaluate the amount of PA and MS undertaken. To assess whether PA and MS knowledge and participation is influenced by sport preference.

Methods 17

All data was analysed using the statistical packages for the social sciences software (SPSS version 23.0). 72% of participants said they were aware of the existence of PA guidelines, however only 6.2% answered correctly for the amount of PA recommended per week. 25.6% correctly documented 2 MS days per week. 21.1% of participants failed to reach 150 minutes PA per week, with 59.6% performing MS exercise on less

than 2 days per week. There was no significant difference between sports for time spent sedentary or time spent physically active

• •


When we compared number of days per week of MS exercise between sports, there were statistically significant results (Figure 1). Football fans performed the most MS exercise, mean 2.32 (SD 2.01), followed by Rugby 1.48 (SD 1.63), Cricket 0.77 (SD 1.37) and Horse Racing 0.72 (SD 1.29). P<0.001.

There was a significant difference between sports for participant perspective of how active they are (p=0.004) (Figure 2).

The majority of sports fans do meet the DOH guidelines for moderate or vigorous PA. This suggests that non-sports fans could be most at risk of physical inactivity. There are statistically significant results to show that fans of more sedentary sports may undertake less MS activity and perceive themselves to be less active. This may be a population of sports fans to target to achieve recommended guidelines. Results suggested a lack of knowledge of recommended PA per week. Further education is required across the population.

Limitations More participants are required to make conclusions with more certainty. Interpretation of physical activity can be subjective and using questionnaires may increase the chance of response bias by participants.

Acknowledgements Thanks to the Durham CCC, Sunderland AFC, Newcastle Falcons RFC and Newcastle Racecourse involved for enabling data collection at their fixtures. Thanks to G.Kimpton, A.Love, A.Reece-Evans, J. Rammell and A.Okonkwo for their assistance in data collection.

References 1. World Health Organisation. Physical Activity.2016 2. NHS. Benefits of Exercise. 2015 spx 3. Department of Health, UK physical activity guidnelines 2011 -activity-guidelines



Q&A WITH ROGER HAWKES Dr Roger Hawkes MB ChB Dip. Sports Med. FFSEM (UK& Ire) is a consultant Sport and Exercise Physician and the Chief Medical Officer of the European Tour (golf) and has been the European  Team Doctor at the last 4 Ryder Cups including the remarkable turnabout in Chicago in September 2012. Q: Roger - you have amassed over 20 years experience working in professional golf, and over a decade as Chief Medical Officer of the European Tour. Can you give an insight into how things have changed during that time?

and ultimately it was an increased focus on anti-doping that led to its funding. There was a duty for sporting organisations to initiate clear anti-doping policies, and that set the ball rolling. We asked at the time, why not have a sports medicine service too? Their response was “.. well it won’t catch on, but you can try for a year” and it caught on. Now we cover over thirty tournaments globally, and have clinicians in the Middle East and Singapore who provide support when competition is taking place in that part of the world.

RH: When I first arrived in the early nineties, there was a single physiotherapy truck on the Tour which was operated by physios from Belgium and Holland. This was at a time when players were using their own practice balls and collecting them themselves, so the level of professionalism that we see today was a distant prospect. Early on I believed it was a good idea to have doctors and physiotherapists working together in a multidisciplinary team, because what we were seeing was golfers arriving from different parts of the world where they were visiting a range of different clinicians with a limited understanding of common golf pathologies or the nuances of the sport, and subsequently the outcomes weren’t always satisfactory.

Once again, we continued to be proactive. We recruited experts for the most common pathologies we were encountering , introduced them to golf and began to record what we were seeing formally. Our advisory board includes wrist, hip and shoulder specialists, as well as musculoskeletal radiologists, and this nicely compliments a sports medicine team that really understands golf. We believe this is properly allowing us to address the needs of our professional athletes. The next phase of this collaborative will involve trying to better and

However, it took 15 years of persistent conversations with the Tour to develop a sports medicine service, 20

understand the underlying aetiology and implement appropriate prevention strategies.

RH: This has been on our mind for some time, and the tragic death of a number of caddies during golf tournaments has further emphasised the need to improve their welfare. We are working closely with the University of Edinburgh on research, funded by the European Tour, which will aim to understand the physiological and psychological demands of being a caddy. Initially we are gathering this data with questionnaires, but we hope to eventually measure the actual workload, examine the weights of the bags etc, and I’m hoping this will allow us to better serve this population. There is now an onus on the caddies to be fitter, they will have to be more professional in how they prepare physically and not just in their knowledge of the respective courses.

A key challenge was to get buy-in from the appropriate stakeholders. When we initially discussed research, there were concerns we were going to treat golfers as guinea pigs. However, once we clarified that our research may help to prevent the kind of injuries that took golfers away from the course, the engagement improved rapidly. Q: The research carried out by Tim Gabbett and colleagues on the effects of load in sport has been game-changing for how we manage athletes. Has golf made many inroads into accurately measuring total workload?

Q: Golf is fundamentally an individual sport. However, that all changes every two years when the historic Ryder Cup takes place, and it is now right up there as one of the great team events on the sporting calendar. How does your role change when you work with the European Ryder Cup team?

RH: It is a real hot topic at present. We should be able to better measure load in golf, to make sure our athletes are resilient enough to swing a golf club 200 times a day for 4 straight days, 28 times a year. The measurements in other sports, for example football, where repeated high intensity sprints is an important parameter is not relevant for golf, so we need to think about what is valuable to us. There have been challenges with measuring total shots taken, because while we can do this in competition, practice shots before and after the round are not being included in the final tally. The ideal solution would be a seamless wearable (that the golfers are hardly aware that they have on) which measures the total number of shots played, and would give us a better indication as to how this influences injury risk and performance.

RH: Once it becomes a team sport, the standard duties of team medicine apply. There is a huge emphasis on growing team spirit; one would have thought that with all of the different nationalities that make up the European team that would be difficult, but that hasn’t been the case. Perhaps that’s why we’ve done so well in recent years, because the US team have failed to match our team spirit - however they may have stolen a march on us in Minnesota last year!

Q: There has been objections to wearables in other sports. Do you think this might be an issue for golf?

We take a strong stance on injury and illness prevention. If we lose a player to illness on that final day, we lose the Ryder Cup. If needs be, we advise staff and family members with viral illnesses to stay away from the players during competition week. We monitor players closely in the months leading into the competitio, once they know they’re in the team ensuring they turn up fit is crucial.

RH: As you know there are many intricate rules and traditions in golf, but that is not one we have encountered yet. There may be potential commercial conflicts, but we will cross that bridge once we come to it. Q: A unique aspect of golf medicine which is perhaps not always visible to the general public, is the role that the caddy plays. What steps are being taken to optimise caddy health?

But I also believe encouraging the fun element is incredibly important. These athletes don’t often get the opportunity to be part of a team, and allowing them to have periods away from the public eye, 21

where they can relax and have fun is a key part of the Ryder Cup experience.

benefits are also being felt in those who participate recreationally. Can you tell us about the Golf and Health project which you are undertaking?

Q: Do you have an opportunity to screen your athletes before the Ryder Cup?

RH: Traditionally, recreational golf has had a poor reputation. The usual image is of middle class men, who perhaps were drinking and eating too much. Hence, the idea that golf may actually be beneficial for health was difficult for a lot of people to comprehend. Through Dr Andrew Murray carrying out a PhD on the subject, doing a scoping review of the literature in his first year, we discovered reasonable evidence that golf was associated with increased longevity. An interesting area which may support this is in golf’s effect on strength and balance, and its potential to reduce falls. Additionally, golf seems to have a very positive relationship with improving mental health in its participants, and that’s not just through the benefits of exercise, but also from the social camaraderie, the social cohesion, belonging to a club and sharing common goals. But we need to demonstrate this relationship conclusively now, we can’t just hypothesise that golf is good for health, we must prove it beyond all reasonable doubt. Should we succeed in showing that golfers live longer and that their quality of life is better, then that will truly be something to be proud of.

RH: We used to do so formally, because screening didn’t really exist in golf, but generally the top golfers are screened annually now, anyway. Through communicating with the Captain, we are able to ascertain any players who may have niggling injuries leading into the tournament, and we take steps to address this. We also insist each player has their Vitamin D level measured pre-competition. Nutrition is an important aspect. Obviously, we don’t want people to change their dietary habits just for the Ryder Cup, but we do want them to be knowledgeable around the subject, to be aware that they must fuel themselves appropriately before, during and after the competition. Interestingly, when we played in Valhalla in the US a few years back, we found that we were so focussed on winning over the crowd (signing autographs etc), that the players were forgetting to rehydrate adequately. To tackle this, we weighed them regularly and tracked how much fluids they were taking on board, and were able to implement proper hydration strategies before it became a problem. Q: What is the best advice you can give a young doctor or physiotherapist who is aspiring to work in golf?

Three key take home messages:

• •

Accurately measuring workload is the next great challenge in golf medicine.

RH: Any sport worth its salt has a joint or body part to claim as its own. Football has claimed the knee, rugby has claimed the brain, and the wrist belongs to golf. In the past, there was a poor understanding of the wrist among sports physicians, and we were referring cases that weren’t particularly complicated to specialist wrist surgeons, when in truth, they didn’t really require a surgical input. As a consequence, I have tried to foster better knowledge among trainees and doctors that work on the Tour in the clinical assessment of the wrist.

Any aspiring clinician who hopes to work in golf should focus on mastering their clinical assessment of the wrist joint.

Golf, it appears, is highly beneficial to the physical and mental health of those who play.

Q: Finally, one of the great things about the research you are doing in the professional game is that the 22

Golf & Health – Highlighting How Golf Can Benefit All Curated by Aston Ward of the PGAs of Europe The Golf & Health Project, supported by the World Golf Foundation is working to prove the health benefits of golf, helping to drive an increased participation in golf, improve the public image of the sport, and increasing support for golf in the political arena. Researchers at the University of Edinburgh conducted the largest and most comprehensive study of golf and health, with the very positive results published in The British Journal of Sports Medicine. * Part of the project aim is to show that existing and future benefits that are identified are applicable to individuals of all ages and in all areas of society, not just a specific sub-section of the population.

Key benefits

Physical health

Regular physical activity/ exercise decreases the risk of over 40 major chronic diseases, like type 2 diabetes, heart attacks, strokes, colon and breast cancer

Playing golf likely has significant health benefits for people and can be played from 4 to 104. Spectating at golf events may also have health benefits.

Golf would be expected to have these benefits, and golf specific studies have shown positive impacts on cholesterol, body composition, metabolism, and longevity

Here’s just a selection of the varied benefits golf can have:

Life expectancy

• •

Golfers are at moderate risk of injuries, few of which are serious

Those that play golf live 5 years longer, than those that don’t play.

Mental health

It is likely a considerable portion of this is due to physical activity/ exercise gained playing golf. (study of 400,000 golfers in Sweden 2009, Farahmand)

• • •

Regular physical activity/ exercise decreases the risk of anxiety, depression and dementia

• •

Golf can be expected to have these benefits but more work is needed

Those that earn the least, benefit more- good news battling inequalities.

Golf has been shown to have confidence, self-esteem, self-worth benefits

Those that play more probably live longer than those that play less


Google search you local golf facility such as a club, driving range, mini-golf, indoor centre, simulator, etc.

Golf and physical activity

Our chief medical officers and policy makers including the world health organisation urge all adults to take at least 150 minutes of moderate physical activity per week.

Find a golfing mentor – a friend or family member who plays who can show you what to do

• •

Golf can be conclusively shown to be a moderate intensity physical activity.

Visit your local golf club – the club’s PGA Professional and staff will be glad to help you get started

Walking is better for health than using golf carts.

Get out there and try it! Try having a few swings on a driving range or mini golf and see what it’s like. There will always be someone close-by who can help you out. 

WHAT DOES GOLF & HEALTH MEAN TO YOU? Utilising exercise and physical activity as a means to maintain, improve and promote health is a key role of all SEM physicians. Integral to this role is a sound understanding of the physical demands of a wide variety of sports. Ensure safe and appropriate recommendation to individuals wishing to participate in new activities.

For more information visit

FIND OUT MORE To find out more about the Golf & Health Project visit,

Golf and health provides a compilation of up to date resources for healthcare professionals outlining the amazing health benefits of playing golf, with the lay members area acting as a great tool for the ‘weekend warriors’ to find reasons to play the beloved game more often. 

follow @GolfAndHealth on Twitter and ʻGolf and Healthʼ on Facebook.

Get involved There are plenty of ways people can get into golf:

• •

Find a PGA Professional who can answer your questions and show the ropes Have lessons - either on your own or with friends, lessons are a great way to learn the basics in a fun and comfortable environment.





An Investigation of the long-term effects of a career in professional football on the hips and knees of ex-players Rishi Dhand 1, Dr. Glen Rae 2 1 CT1

Doctor Sunderland Royal Hospital, 2 Former Head of Medical Dept. Sunderland AFC

• •

Inclusion criteria: All 118 UK residents of the Sunderland ex-players association.

Background Ex-professional footballers have been shown to be at higher risk of long-term disability compared with the general population, possibly due to injuries sustained during their careers.1

Design: Patients were divided into groups according to decades of age, as well according to whether they had suffered a knee injury (>4 weeks) during their career (see Table 1).

Although data exists to explore the effects of a career in professional football; Little data exists linking disability to age, as well as to previous injuries in the knees, using arthritis scores.

Measuring disability: The WOMAC Osteoarthritis Index was used to measure function in the hips2 and knees3.

Each question had 5 potential answers ranging from ‘no symptoms’ to ‘extreme’ symptoms and so were scored accordingly from 0-4. There was 2 categories:


To investigate the correlation between age and disability experienced in the hips and knees of ex- players.

• •

To identify if previous footballing injuries are linked to the scale of disability.


Pain and stiffness: range 0-24 (hips), 0-36 (knees). Functional limitation: range 0-100 (hips) 0-68 (knees).

Data Collection: The Questionnaires were posted out. 53 members (44.9%) responded. Age groups 30-39 and 80-89 contained only 2 players each so this data was not included in the age comparison data. Relevant data was

Setting: Sunderland AFC and Sunderland AFC Ex-players Association.


removed for 8 players who had undergone hip replacement (HR) and 6 who had undergone knee


replacement (KR).

The knee scores showed a statistically significant increase in symptoms and functional limitation in footballers who had suffered previous knee injuries. This supports the theory of long term disability.

The hip scores show an increase with age, supporting the theory of a ‘wear and tear’ mechanism rather than previous injury.4

More players are required to further validate the results. The involvement of ex-players from other professional football clubs would significantly benefit the validity of the conclusions.


The unpaired t-test was used for statistical analysis. Comparing Hip and knee scores with age was statistically insignificant but the trend showed an increase in symptoms and disability with increasing age


More patients are required, especially in the under 40s and over 80s. to make conclusions with more certainty.

When we compared previous knee injury vs no previous injury, there were statistically significant results. Knee Symptoms (Fig.1) had a mean difference of 8.307 (C/I ±1.756), p<0.0001. Knee Function (Fig.2) had a mean difference of 14.68 (C/I±4.013), p<0.001

• •

WOMAC ratings for pain are subjective and therefore patient dependent. Measuring average scores means that an age group’s data can be distorted by individual values.

Acknowledgements Thanks to Dr. A. Okonkwo for statistical analysis and Ms. L.Oliver, Mr. W. Young & SAFC ex-players association for their help in data collection.

References 1. Drawer, et al, Propensity for osteoarthritis and lower limb joint pain in retired professional soccer players. 2001.BJSM 35:402-408. 2. Hip disability and Osteoarthritis Outcome Score (WOMAC) 2012;. 3. Knee Injury and Osteopaedic Outcome Score (WOMAC) 2012; 4. Shepard, GJ et al,Ex-professional association footballers have an increased prevalence of osteoarthritis of the hip compared with age matched controls despite not having sustained notable hip injuries. 2003.BJSM 37:80-81 doi:10.1136/bjsm.37.1.80 29

INTERVIEW WITH MICHELE VERROKEN Michele Verroken is the founding director of Sporting Integrity, a consultancy which advises governing bodies about identifying, adopting and managing best practice procedures relating to risk, ethical and integrity standards and issues in sport. Formerly Director of Ethics and Anti-Doping at UK Sport, Michele has worked in elite sport for over thirty years. She currently works as an Anti-Doping advisor to the PGA European Tour and is Secretary of the Commonwealth Games Federation Medical Commission. Here, in conversation with Sean Carmody, Michele outlines the important role clinicians play in anti-doping.

SC: Michele - you have amassed over 30 years working in elite sport, can you tell me what the key challenges you have faced are with respect to anti-doping during that time?

hasn’t been the case in my experience. Players spend a lot of time traveling and are often sleep-deprived prior to performance, so the risk is that they may pursue banned substances that enhance recovery and reduce fatigue. Spectators see a particular image of a golfer on the television, but what they may not have factored into their perception is the travel that golfer has undertaken to get to competition, that they may have been awake since 4am to prepare for a 7.30am tee off. That takes its toll, and this is the juncture at which golfers may be left vulnerable to seeking out banned substances. Additionally, the prohibited list doesn’t exactly help players. The goalposts are constantly changing, the recommendations are not always evidence-based and the list is not sport-specific.

MV: The challenges have generally evolved significantly over time, but one thing that has remained consistent is the need to establish an effective, anti-doping process that fits within the framework of ethics and integrity in sport. This has been very challenging to achieve because the landscape is continually changing in sport - either in WADA’s prohibited list or through the anticipation and fear of what methods might be used inappropriately to gain a performance edge. These suspicions don’t fade away, and ultimately they reflect the fact that our biggest threat is in how we deal with people. It is people, ultimately, who corrupt systems. Every person, and every sport, is different and a ‘one size fits all’ approach to testing will not work. We must be adaptable, and not use generic systems to address individual issues.

SC: What methods do you use to disseminate your anti-doping messages to golfers? And when they need confidential advice, who can they go to for it? MV: I have been fortunate to work with The European Tour who have been very proactive with educating the players throughout their careers on anti-doping issues. We have booklets containing permitted medications. I also have the opportunity to have one-to-one discussions with the players, which builds rapport and increases the likelihood of the players going through appropriate channels to ask about various products before consuming them. We try to push the message, in

SC: Certain sports have had reluctant associations with performance enhancing drugs (PEDs) over the years, eg EPO and cycling, what PED might a golfer be at risk of taking in order to improve their performance? MV: There is a general risk of the use of any performance enhancing drug. Initially there had been a worry that beta-blockers might be abused, but that 30

conjunction with the medical team, that performance can be improved within the rules of the game by making good lifestyle choices around sleep, hydration, nutrition and conditioning.

The timescale of TUEs is also a concern. I don’t think the timescale for reviewing an application should be dictated by the bureaucracy of administration. By forcing athletes to apply for TUEs thirty days in advance makes it seem as though we’re inviting people to make appointments to be ill. Consequently, we operate in a different system in golf, with a rapid response to applications.

SC: Over the years you’ll have come across a lot of doctors and physios working in sport , what do you think the sports medicine profession can do to uphold integrity in sport?

SC: Clearly there are lots of issues to be considered. What other challenges are there in the future?

MV: Sports medicine professionals are imperative to upholding integrity in sport. Clinicians need to be conscious of the wider personnel influencing the decisions of golfers - it is equally important that the anti-doping messages reach them too. It is a difficult environment to work in, because golfers are on the road so often, and getting messages to them is not always easy. They must be proactive with how they communicate with golfers, for example when competing in places like China and Mexico, where there are issues with the use of clenbuterol in meat products, it is important that the athletes are aware of these considerations well in advance.

MV: Sport is very vulnerable to corruption now. I am deeply concerned about the growing presence of supplements, and feel there needs to be legislation in place to protect consumers from inadvertently consuming contaminants which may lead to failed drugs tests. There is also a worry about how the general public consume supplements, some of which don’t meet appropriate quality standards or include the ingredients stated on the label. As a general rule, I tell golfers “If it’s too good to be true, it generally is..”, we pride ourselves on being able to offer advice around real food, proper hydration strategies, and let that be the focus of how golfers improve performance rather than reaching for questionable ‘quick-fix’ supplements.

SC: Following on from that Michele - what do you think can be done to limit the abuse of the therapeutic use exemption system?

SC: SC: Finally, can you give your three key tips for any clinician working in sport with regards to preventing doping?

MV: There are a number of issues with the TUE system. Firstly, there have been shortcomings in how information is stored, with golfers having been victims of hacking. This breach of security is untenable going forward. There is also this unfounded perception that the public should have open access to players’ data in the name of transparency, but this will achieve little except discouraging athletes to come forward when they have genuine medical conditions, such as depression. What if their medical condition was to affect their earnings through loss of sponsorship opportunities?

MV: I have got three simple messages. Firstly, you must keep up to date with the anti-doping rules and the content on the prohibited list, and to consider the implications of any changes. Significant changes must be communicated well to your athletes. My second tip is to encourage clinicians to strike the balance between being approachable and professional. You are not the player’s friend, you are their doctor, and that patient-clinician dynamic must be maintained. Nevertheless, athletes should feel comfortable to discuss sensitive issues with you.

I strongly believe players should be able to openly ask about substances without raising suspicion. I’m also proactive with letting them know what medications they can take, for example sildenafil for erectile dysfunction many would be embarrassed to have even asked about that, and they may have suffered as a result. But actually, by sharing that information with them, it may make life easier.

Finally, protecting the health of your athletes must be your priority. At the end of the day, a career in sport is finite, and you have to bear in mind the player’s long term health.



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USEMS e-Mag (E5)  

Fifth Edition of the USEMS e-Magazine. Our theme this quarter is Golf Medicine.

USEMS e-Mag (E5)  

Fifth Edition of the USEMS e-Magazine. Our theme this quarter is Golf Medicine.