Golf - It's War Out There

People get a lot out of golf, but consider the reverse proposition. Lacking any apparent aggression, a demure little golf ball can take just as much out of you as you can take out of it. Golf – it’s war out there!

Take Peter Jacobsen for instance, certainly one of the premier warriors in the ironically named ‘game’ of Golf. In his battles over the years, Golf has managed to take back a right knee, a left hip, and several parts of his lower back. He told me recently that he’s still going back for more!

As for back injuries, Peter Jacobsen has lots of company. Worldwide, mountains of epidemiologic studies tell us that 65% - 80% of people in developed countries will suffer from incapacitating back pain at some time in their lives, and the first episode is surprisingly often in the under 30 age group.

Overall, we don’t really know if back problems are more common in golfers than, say, other matched populations where people bend over, lift and twist a lot. What we do know is that back injuries are by far the most common injury in golf, accounting for at least 25% of all of them. By way of perspective, the next categories down the list are injuries to the leading wrist, elbow and shoulder, accounting for roughly 7% each.

Myths about Causes

Lifting and loading is bad for backs, right? Well, no says colleague and spine expert Tapio Videman MD. In a series of recently published papers from his Scandinavian Twin Study population, Professor Videman shows that loading – lifting constantly over a lifetime – is actually protective of the spine. Good news for lumbar loaders like runners, moms and dads with kids and, well, most of us.

People invariably think that ‘bulging disks’ in MRIs of their lower backs means that they’ve got a problem and that they’ve found the cause. But a landmark Swedish study of over 1200 people without any back pain found that 48% had ‘significantly bulging disks’.

Another favorite shibboleth is ‘degenerative disc’ disease, very frequently reported in imaging studies of the lumbar spine. Professor Videman shared MRI examples of two spines with extensive degeneration. One of the two 56 year old men had had 7 lifetime episodes of incapacitating back pain; the other had none. Both were farmers, neither of them was a golfer. Two ‘degenerated’ backs – one with recurrent pain, the other without. They were identical twins.

By far the most common cause of back pain is straining or spraining the muscles and supporting ligaments. When we study the motions that people do on an everyday basis and coordinate these with onset of pain, we find that the two most common movements associated with straining the back are a lifting motion that occurs with rotation. Hmmm, that sounds like a golf swing.

Arrrgh – What to Do?

Overwhelmingly, backs do get better, but sometimes they ache for years. Peter said that his back problems started in about the mid 1990s and just nagged on. The symptoms were general back aches, stiffness, difficulty standing fully erect, and from time to time a sense of pain radiating down the back of both legs. After right knee replacement in 2006, and then a new left hip the next year, he decided he wanted to do something about his back.

Surgery – or not?

‘Failed Back Syndrome’ - back surgeries where the patient’s pain is unchanged or worsened – is a frustrating problem. University of California Neurosurgeon Philip Weinstein MD and Orthopedic spine specialist Phil Orisek MD both agree that surgery is best reserved for those suffering intractable pain [really bad pain] and/or those with some kind of neurologic or muscular deficit [loss of feeling or some muscle function] that just doesn’t get better with medicines or any of the zillion therapies for bad backs. And then the next question is …

What Kind of Surgery?

Scopes of one kind or another have made surgical interventions for gall bladders, knees, shoulders, obesity and many others a lot less traumatic. Arthroscopes [in joints] and Endoscopes [in the body but not joints] have been around for decades and make ‘minimally invasive surgery’ possible. Spine surgeon, Phil Orisek MD, routinely does a variety of procedures through a 16 millimeter incision and scope and the results can be pretty amazing. Orisek cited several cases of ‘surgery on Friday and back to work on Monday as examples. But that’s not everyone, he cautions.

The basic approaches to surgery that have been much studied and in use for decades are: 1. Remove material – bone, discs, etc. – that is pressing on the spine or nerve roots [laminectomy, foraminotomy] 2. Stop motion of the vertebral segments [fusion, screws, etc]

Beyond these exist a gigantic variety of treatments that have been tried, including chymopapain injections [from the papaya plant] and much more recently, very high temperature lasers which ablate [burn the #$%@ out of] offending tissue. Among dozens of others.

What about lasers?

Unfortunately, we don’t have very much information on the use of lasers for ablating discs and other areas of the spine. There are no large trials, and the very few ‘studies’ reported in medical literature are by clinicians reporting their early trials. One author in Santa Monica CA, reviewing his own cases, categorized 56% of 113 cases as having fair to poor results. He said more trials are needed.

But Peter Jacobsen, who’s a paid spokesperson for the Laser Spine Institute says the results of his 3 back surgeries at the Institute really helped him. Two of the surgeries were apparently for “moderate spinal stenosis” and were performed one week apart on each side of his lumbar spine. About a month before these surgeries, Peter said he had surgery on the facet joints of his lumbar spine.

Whew! Three back surgeries in something like 3 months doesn’t sound like a lot of fun.

Winding up our conversation, the famously affable Peter told me that he’s back in the gym and looking forward to taking some more out of the game that has taken so much out of him!

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