Prolotherapy for Golfing Injuries and Pain
Golf is a very popular sport in the U.S. and many other countries. This is, in part, from the non-contact nature of the sport, allowing many different age groups to play, both older and younger participants. Golf is a sport where high performance and skill are not limited by age.1 Surveys estimate anywhere from 28.7 million2 to 37 million3 golfers in the U.S. alone, with golfers’ reported annual spending estimated at 24 billion dollars per year on equipment and fees.4 Despite the low impact nature of the sport, several studies over the years have shown that golf has its share of injuries resulting in musculoskeletal pain in the amateur as well as the professional golfer.5-9
Prolotherapy is a non-surgical procedure which stimulates repair of musculoskeletal injuries. This treatment has received increased attention over the last few years, and made its way into the sports world, as well as The New York Times which reports: “Unlike many drugs and surgery, prolotherapy has minimal side effects when performed by an experienced practitioner…”10 The purpose of this article is to explore common golf injuries, contributing factors, diagnosis, prevention and non-surgical treatment options with prolotherapy.
Prolotherapy is a method of injection treatment designed to stimulate healing.11 Many different types of musculoskeletal injuries and pain lend themselves to prolotherapy treatment including low back and neck pain, chronic sprains and/or strains, whiplash injuries, tennis and golfer’s elbow, knee, ankle, shoulder or other joint pain, chronic tendonitis/tendonosis, and musculoskeletal pain related to osteoarthritis. Prolotherapy works by raising growth factor levels or effectiveness in connective tissue ligaments and tendons to promote repair or growth.12
Prolotherapy lends itself very well to sports injury and pain because most sports related injuries involve ligaments and tendons. Prolotherapy can be used years after the initial pain or problem began, as long as the patient is generally healthy.
Significant athletic injuries that hinder a person in playing their sport are almost always ligamentous or tendonous in nature, not muscular.13 This is because ligament and tendon tissues have a poor blood supply, as opposed to muscles which have a large blood supply and so that they take longer to heal than other tissues—usually four to six weeks. Since the ligaments are the main stabilizing forces in the joints, these are the structures that take the bulk of the forces while the athlete is playing his/her sport.14 Unfortunately, incomplete healing is common after injury to those structures.15,16 In fact, it has been estimated that the usual best result of a completed connective tissue repair process is a return to normal connective tissue length, but only 50% to 60% of pre-injury tensile strength.17 Over time, and multiple injuries, this can result in laxity and connective tissue insufficiency.18 In repetitive trauma, common in golf related injuries,19 each individual trauma may be insufficient to provide enough stimulus to prompt complete healing, so that even minor injury may be enough to accumulate damage to the point of initiating chronic pain.20
Prolotherapy works by causing a temporary, low grade inflammation at the site of ligament or tendon weakness (fibro-osseous junction) thus “tricking” the body into initialing a new healing cascade. Inflammation activates fibroblasts to the area, which synthesize precursors to mature collagen, and reinforce connective tissue.21 This inflammatory stimulus raises the level of growth factors to resume or initiate a new connective tissue repair sequence to complete one which was prematurely aborted or never started.22 Prolotherapy is also known as “regenerative injection therapy (RIT),” “non-surgical tendon, ligament and joint reconstruction” and “growth factor stimulation injection therapy.” “Sclerotherapy” is an older, inaccurate term for prolotherapy, based on the original theory that scar formation was the treatment mechanism. However biopsy studies have not demonstrated scar formation with prolotherapy agents currently in use.23 Rather, studies have shown a proliferation of new, normal, thicker and stronger connective tissue after Prolotherapy injections (thus “prolo” for proliferation).24 A typical course is four to six treatments, spaced from two to six weeks apart.
Common Injuries in the Amateur and Professional Golfer
The most common injury reported by the amateur and professional golfer alike is in the low back/lumbar spine/sacroiliac region pain.25-28 This makes sense when looking at the powerful rotation and extension motion in the golf swing.29 In the professional golfer, the second most commonly injured area is the wrist or hand, followed by the shoulder.30,31 For the amateur, the second most commonly injured area is the elbow, followed by the wrist or hand, and then the shoulder.32,33 Overuse is a large component of injury both in the professional and the amateur golfer and, more often, the cause of injury than direct trauma.34 One study reports 82.6% of all reported injuries involve overuse, with more than 90% of low back injuries attributed to overuse. Only 17.4% of injuries reported in that study were attributed to single trauma events.35 Another report found that professional golfers’ injuries occurred primarily from overuse during practice (68%) with only 7% during competition.36 Wrist injuries occur most commonly in the lead wrist (left wrist in right handed golfers). This is also true of shoulder injuries where 90% of shoulder injury involve the lead shoulder.37,38
The Golf Swing
In order to correctly analyze golf injuries, it is important to understand the components of the golf swing itself. Golfers may give a history of symptoms that occur only during one specific phase of the swing and an understanding of the swing components will help in diagnosis.39 Problems with swing mechanics have been blamed for many of the injuries seen in golf,40 especially low back pain41 and shoulder injuries.42 The swing requires a coordinated and synchronized effort of muscle strength, timing and coordination on the part of the golfer to generate clubhead speeds often over 100 mph.43 It is no wonder then that many injuries are reported to occur during the golf swing, most commonly at ball impact, as well as follow-through and the backswing44,45 (see Figure 1).