Estimates of Golf-Related Upper Extremity Injuries in the United States: A 10-Year Epidemiology Study (2011-2020)

Abstract

Background:

Golf is one of the most popular sports in the United States (US) and is played by participants of all ages and skill level. Given the popularity and sport-specific demands on the upper torso, golf poses a considerable risk for upper extremity (UE) injuries. Therefore, the aim of the current study was to (1) determine the incidence rate of UE golf injuries presenting to emergency departments (EDs) in the US, (2) determine the most commonly injured body parts and mechanisms of injury, and (3) compare current injury epidemiology with previous trends in the literature.

Hypothesis:

Male sex, bimodal age extremes (young and elderly), and utilization of golf carts (vs walking) are associated with a higher incidence of golf-related UE injuries.

Study Design:

Descriptive epidemiology study.

Level of Evidence:

Level 3.

Methods:

The National Electronic Injury Surveillance System (NEISS) is a statistically validated injury surveillance system that collects data from ED visits as a representative probability sample of hospitals in the US. We queried the NEISS for the years 2011 to 2020 to examine the following variables for golf-related UE injuries: sociodemographic, diagnosis, body part, and mechanism of injury.

Results:

From 2011 to 2020, there were a total of 1862 golf-related UE injuries presenting to participating EDs, which correlates to an estimated 70,868 total injuries. Overall, male golf players were disproportionately affected (69.2%) versus female golf players (30.8%) and the most commonly injured age groups were those aged >60 and 10 to 19 years. The most common injuries included fractures (26.8%), strains/sprains (23.4%), and soft tissue injuries (15.9%). The joints injured most frequently were the shoulder (24.8%), wrist (15.6%), and joints in the hand (12.0%). The most common mechanisms of injury were cart accidents (44.63%), falling/tripping (29.22%), and golf club swinging/mechanics (10.37%).

Conclusion:

Golf-related UE injuries can be acute or due to chronic overuse. Male athletes >60 years of age were the population most commonly presenting to the ED with a golf-related injury. Further, the shoulder, forearm, and wrist were most commonly injured. These findings are consistent with previous epidemiological trends in the literature. Interventions to reduce the incidence of injury should be sport-specific and focus primarily on equipment and golf cart safety and swing modification to optimize the biomechanical function of the UEs.

Clinical Relevance:

Our findings indicate that golf-related injury prevention programs should target UE injuries, particularly among young (<19) and older (>60 years) golfers with poor swing mechanics.

Over the last decade, golf has continued to be one of the most popular sports in the United States (US). ²⁶ According to the National Golf Foundation, there were an estimated 36.9 million players in the US in 2020, with over 502 million rounds played. ⁹ This sport is particularly unique in that players of all ages and skill levels can participate. Although levels of interest and dedicated practice time may vary, participants have incredible career longevity, as studies have demonstrated that people actually play more frequently as they age. ²¹

While golf is considered to be a largely low-impact sport, the lifetime injury incidence among amateur golfers is strikingly high, with estimates ranging from 25.2% to 67.4%.^1,21 Further, upper extremity (UE) orthopaedic injuries are extremely common and may account for up to 32% of all golf injuries.^4,14 Although several mechanisms of injury have been proposed - including repetitive overuse, poor swing mechanics, lack of warm-up, and equipment malfunctions - none have been fully elucidated. ¹³ If left untreated, these acute UE injuries may lead to chronic, debilitating musculoskeletal conditions.

Despite the sport’s wide popularity at both the professional and amateur level, there is a dearth of orthopaedic literature exploring the epidemiology of UE golf injuries in the US. In addition, most studies reporting on injury trends have been derived from retrospective surveys or small-database studies and focus primarily on lower back injury.^1,2,4,12 Assessing the demographic risks and overall incidence trends is critical for developing effective injury-prevention protocols and ensuring medical providers are properly equipped to treat golf athletes.

Therefore, we sought to examine and compare the total incidence of UE golf injuries in the US over the last 10 years (2011-2020). Specifically, the aims of the current study were to (1) determine the incidence rate of UE golf injuries presenting to emergency departments (EDs) in the US, (2) determine the most commonly injured body parts and mechanisms of injury, and (3) compare current injury epidemiology with previous trends in the literature.

Methods

This retrospective cross-sectional descriptive epidemiological study was determined to be exempt from institutional review board approval. Data were obtained using the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS). The NEISS is a randomized, statistically validated injury surveillance system that collects data from ED visits as a representative probability sample of all hospitals in the US. This sample, which includes patient demographics, can then be used to calculate a weighted estimate of the total incidence of specific injuries associated with specific “consumer product codes.” These codes are assigned to each patient and designate the activity engaged in at the time of injury. This allows the NEISS to generate a statistically valid and reproducible epidemiological database. Patient medical records are reviewed by designated professional coders employed by the NEISS for each participating hospital. This database has been used previously to generate epidemiological injury patterns for many common orthopaedic conditions.^3,5,6,8,9,22

The NEISS database was queried from 2011 to 2020 to examine the following variables for golf-related UE injuries: sociodemographic, diagnosis, body part, and mechanism of injury. Golf-related injuries were selected using product codes 1212 (Golf activity, Apparel or Equipment) and 1213 (Golf Carts, Motorized Vehicle), and UE injuries included Body Part Codes for the Upper Extremities: Shoulder (30), Elbow (32), Long Arm/Forearm (33), Wrist (34), Upper Arm/Trunk (80), Hand (82), Finger (92), and Head/Neck/Face (75, 76, 89). This 10-year span represents the most recent longitudinal data available from the NEISS database. To ensure reliability, we reviewed the chief complaint/narrative to ensure the injury was indeed sustained during golf participation and was isolated to the UE. Patients who did not present with golf-related injuries stratified by the product codes described above and those who had any associated secondary injury (ie, fracture and a dislocation) were excluded from the cohort. Following our stratification, the NEISS database yielded 1862 golf-related UE injuries presenting to the ED from 2011 to 2020.

The descriptive epidemiological data available for the 1862 cases was analyzed using the following variables: age, sex, disposition, time (intervals by 1-year from 2011 to 2019), and mechanism of injury (narratives). These data were used for both raw calculations (n) and estimated weighted and adjusted injury counts (N) that were generated automatically by the NEISS database with 95% upper and lower confidence intervals (CIs) for the entire population.

For all national estimates of incidence, upper and lower bounds of a 95% CI were calculated around the weighted estimate by the NEISS query database using the given coefficient of variation and national estimate. We performed all descriptive statistical analyses using IBM SPSS Statistics (Mac Version 27.0, IBM Corp). For all contingency table comparisons of categorical variables (ie, age groups vs sex distributions), we used either chi-square or Fisher’s exact tests as appropriate. Statistical significance was set at P ≤ 0.05 a priori.

Results

Demographic Breakdown

From 2011 to 2020, US EDs participating in the NEISS program recorded a total of 1862 golf-related UE injuries. Using the algorithm provided by the NEISS database to calculate estimated national incidence using 95% CIs - which utilizes machine learning to apply standardized injury events and source codes based on a representative probability sample and U.S. Census data - this correlates to 70,868 total UE golf injuries in the US over a 10-year period. This represents approximately 7086 injuries per year among all golf players presenting to the ED.

Table 1 provides a comprehensive overview of demographic variables analyzed in the study including age, sex, and disposition with CIs as available by the NEISS database. Overall, in terms of incidence, male golfers were disproportionately affected (n = 1289, 69.2%) compared with female golfers (n = 573, 30.8%), regardless of age group (P < 0.05). These data represent a male:female injury proportion ratio of 2.24:1. Further, there was a bimodal distribution of the age groups most commonly affected: 10 to 19 and >60 years old. In terms of disposition, most patients who presented with UE injury were treated/examined with subsequent discharge from the ED (Table 1).

Table 1.

Demographic variables for those treated in US EDs for golf-related UE injuries, NEISS 2011 to 2020

Demographic Variable	n	National Estimate (95% Lower CI; Upper CI)	%
Overall Total patients	1862	70,868 (43,994; 97,743)	-
Age group, years
0-9	156	6236 (2416; 10,056)	8.4
10-19	342	14,843 (9070; 20,615)	18.4
20-29	165	8140 (6257; 10,023)	8.9
30-39	171	7660 (5858; 9462)	9.2
40-49	162	7542 (5500; 9585)	8.7
50-59	208	11,607 (7784; 15,431)	11.2
>60	658	14,840 (7109; 22,571)	35.3
Sex
Male	1289	49,040 (26,875; 59,619)	69.2
Female	573	21,828 (11,582; 27,128)	30.8
Disposition
Treated/examined and discharged	1743		93.6
Treated and transferred	5		0.3
Treated and admitted/hospitalized	93		5.0
Held for observation	7		0.4
Left without being seen	14		0.8

ED, emergency department; NEISS, National Electronic Injury Surveillance System; UE, upper extremity; US, United States.

Ten-Year Incidence Trends

From 2011 to 2020, the total incidence of golf-related UE injuries was highly variable but demonstrated a slightly increasing trend line. On a per year basis, the number of injuries were not statistically different (P > 0.05) for any year, though both sex groups did display a trend of incremental increases in total injuries per year from 2011 to 2020. Further, male golfers had a significantly higher incidence for every year of the study (P < 0.05) (Figure 1).

Figure 1.

Nationally estimated number of UE golf injuries stratified by sex, NEISS 2011 to 2020 (P < 0.05). NEISS, National Electronic Injury Surveillance System; UE, upper extremity.

Descriptive Injury Characteristics: Age, Sex, Body Part, and Diagnosis

In terms of injury characteristics, a full distribution with subset analysis of sex and age breakdown is presented in Table 2. For all diagnoses and anatomic locations, male golf players were more commonly affected. The most common injuries diagnosed included fractures (26.8%), strains/sprains (23.4%), and soft tissue injuries (15.9%). Among the major UE joints, those most frequently affected were the shoulder (24.8%), wrist (15.6%), hand (12.0%), and elbow (10.8%). For age distribution, those aged 0 to 29 years sustained the majority of fractures (54.3%), lacerations/amputations (44.9%), soft tissue injury (44.3%), and internal organ injury (42.9%) compared with those aged 30 to 59 and >60 years. Those aged 30 to 59 years more commonly sustained strain/sprains (40.0%) and dislocations (41.5%). Finally, those aged >60 years sustained the most nerve damage (72.7%) and “other” injuries (46.2%). The older populations (>60 years) were more likely to injure their head/neck/face, shoulder, and upper arm/trunk compared with the other age groups. On the other hand, younger golfers (<29 years) had a higher incidence of elbow, forearm, wrist, and finger injuries.

Table 2.

Injury characteristics for golf-related UE injuries, NEISS 2011 to 2020

Variables	N	%	Male Golfers (vs Female Golfers), %	Age Groups (years), %
Diagnosis				0-9	10-19	20-29	30-39	40-49	50-59	>60
Soft tissue injury (contusion, abrasion, hematoma)	296	15.9	58.4	11.5	25.3	7.4	10.8	8.1	10.1	26.7
Strain/sprain	435	23.4	75.4	1.1	9.4	9.7	13.6	12.4	14.0	39.8
Fracture	499	26.8	57.1	18.8	27.7	7.8	5.6	6.0	7.6	26.5
Dislocation	53	2.8	81.1	1.9	9.4	13.2	13.2	13.2	15.1	34.0
Laceration/amputation	147	7.9	76.1	6.8	23.8	14.3	6.8	5.4	5.4	37.4
Nerve damage	11	0.6	81.8	0	0	0	0	18.2	9.1	72.7
Internal organ injury	14	0.8	50	14.3	28.6	0	7.1	14.3	0	35.7
Other (burns, crushing, concussion, foreign body, dental injury, puncture, hemorrhage, electric shock, avulsion)	407	21.9	80.6	2.5	10.8	8.4	8.4	8.6	15.2	46.2
Body part
Head/neck/face	29	1.6	55.2	9.5	23.8	0	14.3	9.5	0	42.9
Shoulder	461	24.8	75.1	3.3	10.4	10.2	14.1	9.1	13.9	39.0
Upper arm/trunk	141	7.6	66.7	11.1	19.3	2.2	8.1	7.4	11.9	40.0
Elbow	201	10.8	70.6	10.4	21.4	6.5	6.0	9.5	11.9	34.3
Forearm	322	17.3	64.0	17.1	25.5	5.9	6.5	4.3	8.1	32.6
Wrist	290	15.6	60.3	6.2	21.4	10.7	7.6	10.3	12.4	31.4
Hand	223	12.0	77.1	6.3	18.4	10.3	9.4	9.4	10.8	35.4
Finger	178	9.6	71.9	8.4	18.0	15.2	7.9	9.6	8.4	32.6

NEISS, National Electronic Injury Surveillance System; UE, upper extremity.

Mechanisms of Injury

The full distribution of UE injuries mapped by body part is visualized in Figure 2. The most common golf-specific mechanisms of traumatic UE injuries were cart accidents (44.63%), falling/tripping (29.22%), and golf club swinging/mechanics (10.37%) (Figure 3).

Figure 2.

Percent distribution of UE injuries mapped by body part, NEISS 2011-2020. NEISS, National Electronic Injury Surveillance System; UE, upper extremity.

Figure 3.

Mechanism of injury for UE golf injuries, NEISS 2011-2020. NEISS, National Electronic Injury Surveillance System; UE, upper extremity.

Injury Location by Body Part and Diagnoses

Finally, we report that the most common injuries when analyzing anatomic body part and specific product code diagnoses from the NEISS for UE golf injuries are soft tissue injuries of the forearm, elbow strains/sprains, ulnar/radial fractures, shoulder dislocations, hand lacerations, nerve damage to the wrist (ie, ulnar vs median), and internal injuries to the head/neck/face (eg, neurovasculature) (Table 3).

Table 3.

Summary of UE golf injuries by body part and diagnosis, NEISS 2011 to 2020

Body Part	Soft Tissue Injury	Strain/ Sprain	Fracture	Dislocation	Laceration/ Amputation	Nerve Damage	Internal Organ Injury	Other	Total
Head/neck/face	3	1	2	0	4	0	14	9	33
Shoulder	39	193	70	37	0	0	0	122	461
Upper arm/trunk	13	29	74	0	3	0	0	22	141
Elbow	52	41	32	6	11	0	0	59	201
Forearm (ulna/radius)	77	18	147	0	28	4	0	48	322
Wrist	28	106	93	1	3	6	0	53	290
Hand	62	17	37	1	46	1	0	59	223
Finger	20	27	39	8	47	0	0	33	174
Other	0	0	0	0	0	0	0	17	17

NEISS, National Electronic Injury Surveillance System; UE, upper extremity.

Discussion

The primary findings of this study are that male golfers are disproportionately affected by UE injuries among golf players presenting to the ED, and there is a bimodal age distribution of injury trends. The most common UE injuries were fractures, muscle strains/sprains, and soft-tissue injuries, and the most common anatomic locations of these UE injuries were the shoulder, wrist, forearm, and elbow. Finally, the youngest golfers aged 0 to 29 years experienced more fractures (54.3%) and soft tissue injuries (44.3%) compared with those aged 30 to 59 and >60 years. However, golfers in the >60 year population sustained a larger percentage of nerve damage (72.7%) and miscellaneous UE injuries (46.2%) compared with those aged 0 to 29 and 30 to 59 years.

The National Golf Foundation reports that approximately 75% of golfers are male and 25% are female. In the present study, female golfers represented approximately 30% of the golfing population. Although this may be a marginal overrepresentation for female golfers, the findings of the present study are largely in agreement with previously published data on golf-related injuries, in which male golfers are affected disproportionately and there is a bimodal distribution for injury by age.^{1-5,10, 23} Specifically for age, participants begin in adolescence but tend to play more frequently as they grow older and therefore have an increased risk of injury, which supports the bimodal age distribution of injuries described in the present study. ²⁶ Walsh et al ²³ validated these findings using the NEISS database from 1990 to 2011, again reporting a bimodal age distribution of injury that was disproportionately male. In summary, UE golf injuries are more common among male athletes, although the exact mechanism requires further study.^4,11,14,15

Despite the popularity of the sport, epidemiological data regarding UE injuries in golf players remain very limited. In the present study, the most common injuries were associated with cart accidents (44.6%), falls/tripping (29.2%), and swinging/golf club mechanics (10.4%). These findings are similar to those of Walsh et al 2017, ²³ who reported that approximately half of golf-cart related injuries were due to either falls or cart accidents. This is likely due to a lack of safety features and oversight on golf carts, which fail to prevent driver or passenger falls. Specifically, many carts do not have brakepads on all 4 wheels, which may lower the level of operator control, especially on uneven terrain and during inclement weather. Further, some carts have rearfacing seating options, which inherently confers a higher risk of ejection to passengers. Similarly, the high percentage of falls/tripping while golfing may be associated with cart injuries, uneven terrain, or varying levels of golf skill. For either proposed mechanism, the primary point of contact with the ground may be an outstretched UE for reflexive, bracing protection or direct impact onto the anterior shoulder or arm, leading to UE injuries. Thus, the high force of impact associated with cart injuries or falls/tripping may lead to a high incidence of accidental, acute UE injuries. ²³

While our data focus on acute injury, other commonly proposed mechanisms of injury include chronic overuse, equipment malfunctions, or being struck by a golf ball on the course.^{1,11,14,17,18} To this point, chronic overuse affects predominantly more skilled and professional golfers, while amateur golfers tend to incur acute injury secondary to poor mechanics or accidental trauma.^{1,11,13,14,17,18} Although chronic overuse injuries are outside the scope and capacity of this study, it is critical to describe these injuries in the literature so that health professionals have a better understanding of both acute and chronic golf injuries and their mechanistic explanations. For example, in their study examining injury rates strictly among amateur golfers, Cohn et al ⁴ observed a slightly more frequent pattern of overuse (54.5%) compared with traumatic injury (45.5%). While we did not observe a high incidence of chronic overuse injuries in the present study (1.93%), this is likely attributed to study design (ie, those presenting to EDs) and the diverse patient cohort.

While golf is traditionally considered a low-impact sport, traumatic injuries are still fairly common and may still be understudied. McHardy et al ¹⁷ illustrated how the biomechanics of a fast-moving golf club compounded with the high force and power-generating torso naturally leads to kinetic chain disruption and UE injury. This may be further exacerbated in amateur players who possess faulty swing mechanics and generate high forces with little control. ¹³ For players like these, traumatic injuries are attributed largely to striking an object other than the ball at impact (eg, the ground) during the swing arc. Subsequently, the wrist and elbow have been proven to be common sites of injury during these acute episodes.^{1,13,14,17,18} McHardy et al ¹⁷ reported that that wrist and elbow injuries accounted for a minimum of 15.8% and 7% of UE injuries, respectively, in a combined sex cohort. Similarly, we found that that wrist and elbow injuries accounted for 15.6% and 10.8% of all UE injuries, respectively.

Our analysis also revealed a high frequency of soft tissue injuries, fractures, and strains/sprains, which have been demonstrated in previous investigations. ¹¹ Specifically, it has been posited that the vulnerability of both the flexor and extensor tendons of the wrist during golf swing and follow-through may explain the high proportion of golfers presenting to the ED with strains or sprains.^1,14 Numerous other groups have supported our findings of the shoulder being the most commonly injured UE joint among golf athletes.^{1,7,11,14,19,20,25,26} While this study was limited to 10-year epidemiological trends, and did not elucidate exact tissue injury mechanisms, we believe that golf-related shoulder injuries are a product of rotator cuff disease and subacromial impingement.^2,24-26 Mallon et al ¹⁶ confirmed these findings and highlighted the role of the rotator cuff in transferring force from the torso/arms down into the golf club during the swing arc. While our study did not explicitly stratify competition level or subanalyze specific muscle groups related to UE injury, the current investigation supports the previous literature, demonstrating that the most common golf-related injuries of the UE joints are the shoulder, forearm, and wrist.^{1,4,11,14,17,19-26}

The present study has significant limitations. Most importantly, the number of injuries and rates are estimates only because of the use of the NEISS database. The NEISS database is an effective tool with which to examine a national representative sample of golf injuries and assess injury patterns; however, there are biases inherent to the database. While we analyzed epidemiologic trends and estimated injury data, the database does not permit the calculation of true injury incidence. In addition, the data do not allow for evaluation of the severity of injuries including surgical intervention, time away from play, or long-term outcomes. Another limitation is that NEISS data do not permit differentiation between acute versus chronic injuries. Overuse injuries can present as acute injuries requiring medical attention, but it is likely that many of the ED visits are due to acute traumatic injuries. Unfortunately, there is not currently an alternate or superior method to investigate national data on overuse injuries in the population of golf players. Finally, this study evaluates data only of patients who presented to the ED and does not include those who may have sought care elsewhere including urgent care, orthopaedic clinics, or primary care offices or those that did not seek medical care.

Conclusion

Golfers presenting to the ED from 2011 to 2020 with UE injuries were disproportionately male >60 years old. The most common injuries were fractures and strains/sprains, whereas the shoulder, forearm, and wrist were the body parts injured most regularly, with cart accidents and falling/tripping being the most common mechanisms of injury. The findings presented provide epidemiological background and staging to inform and equip physicians to engage in patient education and targeted injury prevention strategies for golfing activities to adequately manage the variety of UE injuries in golf.