Article, Sports Medicine

Golf-related injuries treated in United States emergency departments

a b s t r a c t

Objective: This study investigates unintentional non-fatal golf-related injuries in the US using a nationally repre- sentative database.

Methods: This study analyzed golf-related injuries treated in US hospital emergency departments from 1990 through 2011 using the National Electronic Injury surveillance System database. injury rates were calculated using golf participation data.

Results: During 1990 through 2011, an estimated 663,471 (95% CI: 496,370-830,573) individuals >= 7 years old were treated in US emergency departments for golf-related injuries, averaging 30,158 annually or 12.3 individ- uals per 10,000 golf participants. Patients 18-54 years old accounted for 42.2% of injuries, but injury rates per 10,000 golf participants were highest among individuals 7-17 years old (22.1) and >= 55 years old (21.8) com- pared with 18-54 years old (7.6). Patients >= 55 years old had a Hospital admission rate that was 5.01 (95% CI: 4.12-6.09) times higher than that of younger patients. Injured by a golf club (23.4%) or struck by a golf ball (16.0%) were the most common specified mechanisms of injury. The head/neck was the most frequently injured body region (36.2%), and sprain/strain (30.6%) was the most common type of injury. Most patients were treated and released (93.7%) and 5.9% required hospitalization.

Conclusions: Although golf is a source of injury among all age groups, the frequency and rate of injury were higher at the two ends of the age spectrum. Given the higher injury and Hospital admission rates of patients >=55 years, this age group merits the special attention of additional research and Injury prevention efforts.

(C) 2017

  1. Introduction

Golf is enjoyed worldwide as a leisure activity and competitive sport. The National Golf Foundation estimates that there were 24.1 million golfers 7 years and older who played at least one round of golf in the United States (US) in 2015 [1]. While golf is viewed as a low-risk sport, acute traumatic and overuse injuries do occur. In 2009, there were N 40,000 golf-related injuries treated in US hospital emergency depart- ments (EDs) [2]. Golf-related incidents were second only to bicycle crashes as a cause of sports-related head injury among children treated at the Medical College of Georgia during 1996 to 2002 [3].

Abbreviations: CI, Confidence Interval; CPSC, United States Consumer Product Safety Commission; ED, Emergency Department; NEISS, National Electronic Injury Surveillance System; RR, Relative Risk; US, United States.

? Address where work was done: Center for Injury Research and Policy, The Research

Institute at Nationwide Children’s Hospital; 700 Children’s Drive; Columbus, OH 43205, United States.

* Corresponding author at: Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital; 700 Children’s Drive; Columbus, OH 43205, United States.

E-mail address: [email protected] (G.A. Smith).

Previous studies have generally focused on the clinical aspects of golf- related injuries [3-10]. A portion of the literature focuses on the traumat- ic mechanisms [3,9-12]. Some studies limit their focus to a particular body region [3,4,6,9,10,13]. Prior epidemiological studies also have dis- tributed surveys to golf team captains or members of a golf club, thus ex- cluding first-time players, people receiving lessons, and the golfer without a club membership from these studies [13-17]. A 2003 German study randomly selected golfers from different golf courses, but this method omits golf injuries sustained at other recreational facilities, such as a driving range [18]. Few studies examine injuries that occurred during practice at home or school, or due to conditions or hazards on a golf course [5,7,11]. In addition, earlier epidemiological studies are now outdated. Two frequently-cited studies conducted in the US by McCarroll, et al. and Batt were published in 1990 and 1992, respectively. Furthermore, these studies had relatively small sample sizes and were not nationally representative [14,15].

The objective of this study is to investigate the characteristics of un- intentional non-fatal golf-related injuries treated in US hospital EDs from January 1, 1990 through December 31, 2011 among individuals

>= 7 years of age. This is the largest nationally representative study con- ducted on golf-related injuries in the US.

http://dx.doi.org/10.1016/j.ajem.2017.05.035

0735-6757/(C) 2017

  1. Methods
    1. Source of data

Data were obtained from the National Electronic Injury Surveillance System , which is operated by the US Consumer Product Safety Commission (CPSC). A network of approximately 100 hospital EDs pro- vides data daily on consumer product-related and sports and recrea- tional activity-related injuries. This network represents a stratified probability sample of the N 5300 hospitals in the US and its territories with a 24-hour ED with at least 6 beds [19]. ED medical records are reviewed by professional NEISS coders in each participating hospital. Data regarding patient age, gender, injury diagnosis, body region in- jured, disposition from the ED, and a brief narrative describing the inci- dent are included in the NEISS database.

Golf-related injuries were identified by the NEISS product code 1212 [20]. Injuries related to golf carts were identified using their own NEISS code (1213) and the case narratives, and were excluded from this study. Other exclusions included injuries attributable to 1) misusing golf equipment, 2) repairing equipment, 3) intentional acts of violence using golf equipment, 4) horseplay, 5) putting golf equipment away, 6) miniature golf, and 7) fatalities. Fatalities were excluded from this study because the NEISS does not capture fatalities well. Among the 47 fatalities that were excluded from this study, 42 were diagnosed as car- diac-related, 1 was struck by a golf ball, 1 was struck by a golf club, and 3 were attributable to other causes. National estimates in this study are based on the weighted data from 15,071 patients >=7 years of age treated for golf-related injuries in US EDs from January 1, 1990 through Decem- ber 31, 2011. Based on data obtained from the US Census Bureau, the Na- tional Sporting Goods Association’s estimated number of individuals

>= 7 years of age who participated in the sport or activity of golf more than one day during the calendar year was used to calculate injury rates from 1990 through 2011 [21,22].

Variables

All NEISS narratives were reviewed to classify the mechanism of inju- ry into one of the following categories: 1) struck by golf ball, 2) injury by golf club, 3) trip/slip/fall on golf course, 4) “playing golf,” 5) overuse in- jury, 6) swinging a club, and 7) other. The “playing golf” category is non-specific and includes cases with narratives that simply state that the individual was injured while “playing golf.” The “overuse” category describes injuries sustained from golfing very frequently, engaging in golf and other strenuous activities in a short time period, or exacerbating a chronic injury. Subcategories of the “other” category included injuries associated with a structure on the course, hitting a fixed structure during a golf swing (“grounding” the club), cardiac-related, exertion/dehydra- tion, reaching/lifting/bending over, and environmental conditions. Cases were assigned to the cardiac-related category if the NEISS narrative indicated the visit was associated with chest pain, myocardial infarction, arrhythmia, or palpitations [23]. In instances of overlap, the mechanism that occurred first temporally received priority. For example, an injury resulting from tripping and falling onto a golf club was classified as a trip/slip/fall mechanism.

Injury diagnosis was categorized as 1) laceration (including the NEISS categories of amputation, laceration, puncture, and non-dental avulsion), 2) soft tissue injury (including contusion/abrasion, crushing, and hematoma), 3) closed head injury (CHI)/concussion (including in- ternal injuries to the head and concussion), 4) sprain/strain, 5) frac- ture/dislocation (fracture or dislocation), and 6) other (including thermal and radiation burn, foreign body, Dental injury, nerve damage, internal injury not to the head, anoxia, hemorrhage, Electric shock, sub- mersion/drowning, and other diagnoses). Body region was grouped as

1) head/neck (including NEISS categories of head, neck, face, eye, mouth, and ear), 2) upper extremity (including shoulder, upper and lower arm, elbow, wrist, hand, and finger), 3) lower extremity

(including upper and lower leg, knee, ankle, foot, and toe), 4) trunk (in- cluding upper trunk, lower trunk, and pubic region), and 5) other (in- cluding injury to N 25% of body).

Disposition from the ED was categorized as 1) treated and released,

2) hospitalized (including treated and transferred to another hospital, treated and transferred for hospitalization, treated and admitted within the same facility, and held for b 24 h for observation), and 3) left against medical advice. Patients were classified into three age groups: children (7-17 years), adults (18-54 years), and older adults (>= 55 years).

Analyses

Data were analyzed using SAS Enterprise Guide 7.11HF3 software [SAS Institute, Cary, NC]. National estimates were calculated using ad- justed Sample weights provided by the CPSC. All data presented in this study are stable national estimates unless stated otherwise. National es- timates are potentially unstable if the sample size is b 20 cases, estimate is b 1200 cases, or coefficient of variation exceeds 33.0%. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated. This study was judged to be exempt by the Institutional Review Board of the au- thors’ institution.

  1. Theory

This study provides a comprehensive epidemiological analysis of na- tionally representative emergency department data covering a 22-year period regarding an important source of sport- and recreation-related in- jury. In addition to being the largest nationally representative study con- ducted on golf-related injuries in the US, it uses golf participation data to calculate injury rates, which is a major strength of the study.

  1. Results
    1. General characteristics

From 1990 through 2011, an estimated 663,471 (95% CI: 496,370- 830,573) individuals >= 7 years of age with golf-related injuries were treated in US EDs, averaging 30,158 (95% CI: 22,562-37,753) injuries an- nually or 12.3 (95% CI: 9.2-15.4) injuries per 10,000 golf participants

>= 7 years of age. The overall injury rate per 10,000 golf participants in- creased slightly from 11.8 (95% CI: 7.7-15.8) in 1990 to 12.7 (7.6-17.7) in 2011 (Fig. 1). The mean and median age of the patients treated for golf-related injuries was 42.7 (standard error of the mean = 2.18) and

43.2 (interquartile range = 21.0 to 62.4) years, respectively. Patients 18-54 years of age accounted for 42.2% of all injuries (Table 1). The annu- al rates of injury by age group are shown in Fig. 2. The frequency and rate of injury were higher at the two extremes of the age spectrum, demon- strating a U-shaped relationship between age and injury (Fig. 3). Chil- dren 7-17 years of age (22.1; 95% CI: 18.3-25.9) and older adults

>= 55 years of age (21.8; 95% CI: 11.5-32.1) had an injury rate per 10,000 golf participants that was almost 3 times higher than adults 18- 54 years of age (7.6; 95% CI: 6.2-9.1). The majority (80.8%) of golf-related injuries occurred at a sports or recreation facility (Table 1). Although males accounted for 75.9% of injuries, the gender adjusted injury rate per 10,000 golf participants was slightly higher for females (13.0; 95% CI: 9.5-16.5) than males (12.1; 95% CI: 9.1-15.1).

Mechanism of injury

The most common mechanisms of injury were injured by a golf club (23.4%) or struck by a golf ball (16.0%), followed by trip/slip/fall (10.4%), swinging a club (4.5%), and overuse (4.2%) (Table 1). Golf club-related injuries accounted for 71.4% of injuries among patients 7-17 years of age. Compared with the other age group, patients 7-17 years of age (RR: 7.08 95% CI: 5.78-8.66) were more likely to be injured by a golf club, while adult patients >= 18 years of age (RR: 4.23; 95% CI: 3.28-

Fig. 1. Estimated annual number and rate of individuals >=7 years of age treated in US emergency departments for a golf-related injury by year and gender, NEISS 1990-2011.

5.45) were more likely to sustain injuries from overuse or swinging a golf club. The proportion of trip/slip/fall-related injuries increased with age and accounted for 17.2% of all injuries among patients

>= 55 years of age. Patients >= 55 years old (RR: 2.63; 95% CI: 2.11-3.28) and female patients (RR: 1.72; 95% CI: 1.49-1.98) were more likely to be injured from a trip/slip/fall than patients 7-54 years of age or male patients, respectively.

Body region injured, diagnosis, and mechanism of injury

Golf-related injuries occurred often to the head/neck region (36.2%) and were commonly diagnosed as a sprain/strain (30.6%) or a laceration (24.1%) (Table 1). One-fourth of injuries occurred specifically to the joints, including the ankle (7.2%), knee (6.5%), shoulder (4.9%), wrist (4.1%), and elbow (2.5%), and 59.9% of these injuries were sprains/ strains. Most head/neck injuries were caused by a golf club (52.6%) or ball (33.3%), and 56.6% were lacerations. Golf clubs were 3.64 (95% CI: 3.10-4.26) times more likely to be associated with head/neck injuries and 2.54 (95% CI: 2.00-3.22) times more likely to result in a CHI/concus- sion than other injury mechanisms. Male patients (RR: 1.77; 95% CI: 1.51-2.09) were more likely to injure their trunk, while female patients (RR: 1.79; 95% CI: 1.38-2.33) were more likely to injure their wrist than the other gender, respectively.

Among patients 7-17 years of age, 81.1% of injuries occurred to the head/neck region and 60.3% were lacerations (Table 1). Among patients

>= 18 years of age, a sprain/strain was the most common diagnosis. Com- pared with the other age group, patients 7-17 years of age were more likely to injure their head/neck (RR: 3.41; 95% CI: 2.91-3.99) or sustain a laceration (RR: 4.27, 95% CI: 3.55-5.14), while patients >= 18 years of age were more likely to injure their trunk (RR: 8.88; 95% CI: 6.57- 12.00), joints (RR: 4.02; 95% CI: 3.39-4.77), or sustain a strain/sprain

(RR: 7.64; 95% CI: 6.24-9.35).

Swinging or grounding a golf club were 1.54 (95% CI: 1.26-1.89) times more likely to lead to joint injuries. Injuries resulting from swing- ing a golf club or overuse were more likely to occur to the trunk (RR: 2.85; 95% CI: 2.45-3.32) or upper extremity (RR: 1.69; 95% CI: 1.51-

1.88) compared with injuries caused by other mechanisms. Injuries from a trip/slip/fall were more likely to occur to a lower extremity (RR: 2.74; 95% CI: 2.28-3.30) and be diagnosed as a fracture/dislocation (RR: 6.34, 95% CI: 5.34-7.53) compared with injuries caused by other

mechanisms. Specifically, a trip/slip/fall was more likely to result in an ankle (RR: 5.80; 95% CI: 5.03-6.69) or wrist (RR: 2.87; 95% CI: 2.28-

3.61) injury compared with other mechanisms.

Disposition from the emergency department

Most patients were treated and released (93.7%), but 5.9% required hospital admission. Among those hospitalized, 18.2% sustained a frac- ture/dislocation. Patients >=55 years of age (RR: 5.01; 95% CI: 4.12-6.09) or patients with a fracture/dislocation (RR: 2.47; 95% CI: 1.67-3.65) were more likely to be admitted than patients 7-54 years of age or pa- tients with other injury diagnoses, respectively.

  1. Discussion

On average, N 30,000 individuals >= 7 years of age were treated for a golf-related injury annually during the 22-year study period, equaling one person every 17 min. These injuries are frequent, in part, because golf attracts a large and diverse population of participants of various skill levels and ages via the handicap system.

In this study, golf clubs were associated with almost one-fourth (23.4%) of all injuries and N 70% of injuries among children 7-17 years of age. These findings are similar to those of previous studies [9,10,24]. Children 7-17 years of age were seven times more likely to sustain an in- jury from a golf club than adults >=18 years of age; this may be attributable to lack of instruction, experience, adult supervision, or misuse of golf equipment. Some of these children may have been standing too close to another person swinging a golf club. An injury from a golf club was more than three times more likely to be an injury to the head and neck region than an injury from other mechanisms. While almost two-third of golf club injuries in this study were lacerations, 66.7% of fractures/dis- locations to the head and neck region were associated with golf clubs. This agrees with an earlier study of pediatric golf-related head injuries reporting that almost half of Skull fractures were caused by a golf club [3]. According to previous studies, excessive play/practice and poor swing technique are two major mechanisms of golf-related injury [5,7, 8,14-18]. However, in this study, b 10% of the injuries were associated with swinging a golf club or overuse. This may be, in part, because over- use injuries are commonly treated in non-emergency settings. During the golf swing, there are shearing, compressional, rotational, and

Table 1

Characteristics of individuals >=7 years of age treated in US emergency departments for a golf-related injury, NEISS 1990-2011.

Age Groups

7-17 years

18-54 years

>= 55 years

Total

Characteristics

N (%a)

N (%a)

N (%a)

N (%a)

95% CI

Gender

Male

105,869 (73.7)

218,826 (78.2)

178,766 (74.5)

503,461 (75.9)

378,322-628,600

Female

37,755 (26.3)

60,856 (21.8)

61,345 (25.5)

159,957 (24.1)

116,738-203,175

Subtotal

143,624 (100.0)

279,682 (100.0)

240,111 (100.0)

663,417 (100.0)

496,314-830,521

Location of Injury

Sports/recreation facility

36,647 (39.2)

188,103 (86.6)

198,470 (93.1)

423,220 (80.8)

276,002-570,439

Other

56,765 (60.8)

29,168 (13.4)

14,617 (6.9)

100,551 (19.2)

80,169-120,932

Subtotal

93,412 (100.0)

217,271 (100.0)

213,088 (100.0)

523,771 (100.0)

368,468-679,074

Mechanism of Injury

Playing golf

4770 (3.3)

97,844 (35.0)

85,255 (35.5)

187,868 (28.3)

120,086-255,650

Injury by golf club

102,543 (71.4)

43,360 (15.5)

9052 (3.8)

154,954 (23.4)

130,220-179,689

Struck by golf ball

25,123 (17.5)

52,267 (18.7)

28,713 (12.0)

106,103 (16.0)

86,695-125,510

Trip/slip/fall

3683 (2.6)

24,112 (8.6)

41,406 (17.2)

69,201 (10.4)

52,045-86,357

Swinging

2448 (1.7)

16,766 (6.0)

10,686 (4.5)

29,901 (4.5)

22,242-37,559

Overuse

1096 (0.8)b

12,776 (4.6)

13,971 (5.8)b

27,842 (4.2)

13,597-42,088

Other

4016 (2.8)

32,557 (11.6)

51,029 (21.3)

87,601 (13.2)

52,186-123,017

Cardiac-related

86 (0.1)b

3379 (1.2)

16,692 (7.0)

20,156 (3.0)

9441-30,872

Exertion or dehydration

605 (0.4)b

4620 (1.7)

13,755 (5.7)b

18,979 (2.9)

7505-30,453

Hazard or foreign body

2224 (1.5)

8888 (3.2)

6343 (2.6)

17,455 (2.6)

13,047-21,862

Environmental

519 (0.4)b

5189 (1.9)

5082 (2.1)b

10,790 (1.6)

6006-15,573

Reaching, bending, or lifting

155 (0.1)b

3417 (1.2)

2470 (1.0)

6042 (0.9)

3803-8281

Grounding club

252 (0.2)b

3504 (1.3)

1567 (0.7)

5322 (0.8)

3572-7072

Other

177 (0.1)b

3561 (1.3)

5120 (2.1)

8857 (1.3)

5287-12,428

Subtotal

143,678 (100.0)

279,682 (100.0)

240,111 (100.0)

663,471 (100.0)

496,370-830,573

Body Region Injured

Head/neck

116,443 (81.1)

83,327 (29.9)

40,008 (16.7)

239,778 (36.2)

199,612-279,944

Lower extremity

8921 (6.2)

66,795 (23.9)

64,968 (27.1)

140,684 (21.2)

94,311-187,058

Upper extremity

13,812 (9.6)

61,338 (22.0)

56,574 (23.6)

131,725 (19.9)

96,841-166,609

Trunk

3699 (2.6)

59,896 (21.5)

58,765 (24.5)

122,360 (18.5)

79,740-164,980

Other

683 (0.5)b

7701 (2.8)

19,190 (8.0)b

27,573 (4.2)

12,442-42,704

Subtotal

143,558 (100.0)

279,057 (100.0)

239,505 (100.0)

662,120 (100.0)

495,271-828,970

Diagnosis

Sprain or strain

7071 (4.9)

106,474 (38.1)

88,997 (37.1)

202,541 (30.6)

124,856-280,226

Laceration

86,435 (60.3)

49,767 (17.8)

23,485 (9.8)

159,687 (24.1)

134,503-184,871

Soft tissue injury

23,644 (16.5)

41,661 (14.9)

27,214 (11.4)

92,519 (14.0)

74,770-110,269

Fracture or dislocation

7738 (5.4)

21,497 (7.7)

25,545 (10.7)

54,780 (8.3)

43,091-66,468

CHI/concussion

10,054 (7.0)

9729 (3.5)

5305 (2.2)

25,088 (3.8)

18,796-31,379

Other

8438 (5.9)

50,236 (18.0)

69,105 (28.8)

127,778 (19.3)

82,816-172,740

Subtotal

143,380 (100.0)

279,363 (100.0)

239,650 (100.0)

662,393 (100.0)

495,411-829,375

ED Disposition

Treated and released

139,246 (97.1)

271,711 (97.3)

209,908 (87.5)

620,865 (93.7)

470,294-771,436

Hospitalized

3844 (2.7)

6247 (2.2)

28,704 (12.0)

38,795 (5.9)

21,271-56,318

Left against medical advice

320 (0.2)b

1350 (0.5)

1252 (0.5)b

2922 (0.4)

1599-4244

Subtotal

143,410 (100.0)

279,307 (100.0)

239,865 (100.0)

662,582 (100.0)

495,678-829,485

a Column percentages may not sum 100.0% due to rounding error.

b Estimate is potentially unstable due to sample size b 20 cases, estimate b 1200 cases, or coefficient of variation N 33.0%.

postural forces on the body; thus, improper swinging technique can lead to injury [6,8]. Amateurs are typically guilty of poor technique and can injure themselves trying to overcome technical deficiencies with force, while a career of playing golf is associated with more overuse injuries which often result from excessive play [5,7,11,15,17,18,25]. In- juries from swinging a golf club or overuse were more likely to occur to the trunk or upper extremity, which is consistent with previous find- ings that these injuries often affect the lower back and wrist [14,16,18, 25,26]. Another injury risk factor associated with swinging a club occurs when a player “grounds” the club against a fixed object or the ground. The impact of grounding can create a strong deceleration force which can result in injury. The joints, especially the wrist, are vulnerable to in- jury from this type of force [11,14,17,26,27].

The repetitive motion of the golf swing places heavy demands on the musculoskeletal system, especially the back region. This explains why the lower back was the most common site of injury reported in previous studies [5,7,11,13-18,27]. Although the trunk (which includes the back), was not the leading body region injured in this study, it accounted for al- most one-fifth of injuries. Stroke mechanics have changed over the years from the “classic” swing to a “modern” version to a hybrid, each with a

different injury pattern [27,28]. Today, many golfers utilize the modern swing because it allows for longer range and higher accuracy [7,17,27, 28]. However, the modern swing limits the rotation of the hips and stresses the spine more than the classic swing that allows the hips to move with the shoulders [7,27,28]. As a result, the modern swing can in- crease the risk of lower back injury [17,28].

Conditions on the course, such as slippery or uneven ground, is an- other factor that may increase the risk of injury to golfers. According to a 2005 study, 10.8% of injuries occurred between shots while traversing the course [17]. In our study, 10.4% of injuries were associated with a trip, slip, or fall on the course, and older patients >=55 years of age were more likely to sustain trip/slip/fall-related injuries than younger patients. The prominence of this mechanism among older patients is most likely at- tributable to age-related declines in strength, agility, and balance [8]. In addition, a trip/slip/fall in our study was more likely to result in an injury to the ankle or wrist than other mechanisms. Ankles, like the head, are more likely to be injured by a single Traumatic event, such as a slip or trip, than by overuse [18]. In addition, when an individual falls, the hands are often used to break the fall; thus, putting the wrist at risk of fall-related injury.

Fig. 2. Estimated annual rate of golf-related injuries among individuals >=7 years of age by year and age group, NEISS 1990-2011.

xIn this study, the head/neck was the most common body region in- jured, and most of these injuries were associated with a golf club or a golf ball. Although golf has been played for centuries, it was not until 1999 that the Royal and Ancient Golf Club of St. Andrews in Britain and the United States Golf Association published a rule in response to golf-related head injuries [29]. Golfers are instructed to ensure that other players are out of range of the club, ball, or any debris during a swing and to alert other players in the line of a shot [30]. Following established guidelines and being aware of surroundings during play can reduce golf-related injury rates. Adult supervision of children playing golf and teaching safety guidelines to children can help prevent pediatric golf-related injuries.

Professional assessment and instruction can correct technical errors and reduce the risk of injury from poor technique. Modifying swing tech- nique may lower the potential for injury by lessening stress on the mus- culoskeletal system, including the lower back [31,32]. Strengthening and

conditioning muscles along with proper warm-up exercises may further mitigate injury risk [5,7,14,16]. The type of equipment can also influence the risk of injury. The material, flexibility and resistance of a club should be tailored to a golfer’s characteristics; for example, using too light of a club may predispose the player to injury because it can be swung harder than necessary [5,17].

Study limitations

This study has several limitations. The number of golf-related injuries reported in this study is an underestimate of the actual number, because only injuries treated in EDs were included. Injuries treated in other health care settings were not captured in this study, and therefore, our findings may not be representative of the entire spectrum of golf-related injuries. NEISS narratives often lacked detail regarding the mechanism of injury and simply stated that the patient was “playing golf” when

Fig. 3. Estimated number and rate of golf-related injuries among individuals >=7 years of age by age group and gender, NEISS 1990-2011.

injured, which limited our analyses. Information was not available re- garding the golfing skill level of patients, how often they golfed, or their level of physical fitness, which are factors that can influence risk of injury. The level of supervision of children while golfing was not doc- umented consistently. The type of equipment used also could not be de- termined from the narratives.

  1. Conclusions

Despite its limitations, this is the largest nationally representative study conducted on golf-related injuries in the U.S. It evaluated injuries over a 22-year period and used golfing participation data to calculate in- jury rates, which is an advantage over previous studies. The findings of this study can help guide future research and inform the development of Prevention strategies. Although golf is a source of injury among all age groups, the frequency and rate of injury were higher at the two ends of the age spectrum. Mechanisms of injury differed between these two age extremes, with golf club-related injuries predominating among the young and trip/slip/fall injuries more commonly seen among older adults. Given than older adults (>= 55 years) had an injury rate that was almost 3 times higher than that of younger adults and a hospital admission rate that was 5 times higher than that of younger in- dividuals, this age group merits the special attention of additional re- search and injury prevention efforts.

Funding source

The authors gratefully acknowledge the student research scholarship funded by the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention that was provided to the first-listed author while she worked on this study (grant number 1R49CE001172). The funding organization did not have any involvement in study design; data collection, analysis or interpretation; writing of the manuscript; or the decision to submit the manuscript for publication. The interpretations and conclusions expressed in this article do not nec- essarily represent those of the funding agency.

Financial disclosure statement

The authors have no financial disclosures relevant to this study.

Conflict of interest statement

The authors have no conflicts of interest relevant to this study.

References

  1. National Golf Foundation. 2015 golf participation in the U.S. – a slight dip tempered by strong positive indicators. http://ngfdashboard.clubnewsmaker.org/Newsletter/ 1ll1udoge19?a=5&p=2389923&t=410871; 2016. [accessed 29.11.16].
  2. National Safety Council. Injury facts. 2011 ed. Itasca, IL: National Safety Council; 2011.
  3. Rahimi SY, Singh H, Yeh DJ, Shaver EG, Flannery AM, Lee MR. Golf-associated head injury in the pediatric population: a common sports injury. J Neurosurg 2005;102: 163-6.
  4. Unverdorben M, Kolb M, Bauer I, et al. Cardiovascular load of competitive golf in car- diac patients and healthy controls. Med Sci Sports Exerc 2000;32:1674-8.
  5. Theriault G, Lachance P. Golf injuries. An overview. Sports Med 1998;26:43-57.
  6. Wallace P, Reilly T. Spinal and metabolic loading during simulations of golf play. J Sports Sci 1993;11:511-5.
  7. Parziale JR, Mallon WJ. Golf injuries and rehabilitation. Phys Med Rehabil Clin N Am 2006;17:589-607.
  8. Lindsay DM, Horton JF, Vandervoort AA. A review of injury characteristics, aging fac- tors and prevention programmes for the older golfer. Sports Med 2000;30:89-103.
  9. Fountas KN, Kapsalaki EZ, Machinis TG, Boev A, Troup EC, Robinson Jr JS. Pediatric golf-related head injuries. Childs Nerv Syst 2006;22:1282-7.
  10. Hink EM, Oliver SC, Drack AV, et al. Pediatric golf-related ophthalmic injuries. Arch Ophthalmol 2008;126:1252-6.
  11. Wadsworth LT. Sideline and event management in golf. Curr Sports Med Rep 2011; 10:131-3.
  12. Brennan PO. Golf related head injuries in children. BMJ 1991;303:54.
  13. McHardy AJ, Pollard HP, Luo K. Golf-related lower back injuries: an epidemiological survey. J Chiropr Med 2007;6:20-6.
  14. Batt ME. A survey of golf injuries in amateur golfers. Br J Sports Med 1992;26:63-5.
  15. McCarroll JR, Rettig AC, Shelbourne KD. Injuries in the amateur golfer. Phys Sportsmed 1990;18:122-6.
  16. Fradkin AJ, Cameron PA, Gabbe BJ. Golf injuries–common and potentially avoidable. J Sci Med Sport 2005;8:163-70.
  17. McHardy A, Pollard H, Luo K. One-year follow-up study on golf injuries in Australian amateur golfers. Am J Sports Med 2007;35:1354-60.
  18. Gosheger G, Liem D, Ludwig K, Greshake O, Winkelmann W. Injuries and overuse syndromes in golf. Am J Sports Med 2003;31:438-43.
  19. Schroeder T, Ault K. The NEISS sample (design and implementation) 1997 to present. Available at: http://www.cpsc.gov/PageFiles/106617/2001d011-6b6.pdf; 2001. [accessed 29.11.16].
  20. U.S. Consumer Product Safety Commission. 2012 NEISS product code comparability table. Available at http://www.cpsc.gov//PageFiles/106517/comptable.pdf; 2012. [accessed 29.11.16].
  21. National Sporting Goods Association. Participation in selected sports activities: 1990-2009. Statistical Abstract of the United States. Washington, DC: U.S. Census Bureau; 1992-2012 online edition. Available at: https://www.census.gov/library/ publications/time-series/statistical_abstracts.html. [accessed 29.11.16].
  22. National Sporting Goods Association. Participation in selected sports activities: 2010-2011. ProQuest Statistical Abstract of the U.S. 2013-2014 online edition. Available at: http://statabs.proquest.com/sa/. [accessed 29.11.16].
  23. Watson DS, Shields BJ, Smith GA. snow shovel-related injuries and medical emergen- cies treated in US EDs, 1990 to 2006. Am J Emerg Med 2011;29:11-7.
  24. Vitale MA, Mertz KJ, Gaines B, Zuckerbraun NS. Morbidity associated with golf-related injuries among children: findings from a pediatric trauma center. Pediatr Emerg Care 2011;27:11-2.
  25. Cole MH, Grimshaw PN. The biomechanics of the modern golf swing: implications for lower back injuries. Sports Med 2016;46:339-51.
  26. McHardy AJ, Pollard HP. Golf and upper limb injuries: a summary and review of the literature. Chiropr Osteopat 2005;13:7.
  27. McHardy A, Pollard H, Luo K. Golf injuries: a review of the literature. Sports Med 2006;36:171-87.
  28. McHardy A, Pollard H. Lower back pain in golfers: a review of the literature. J Chiropr

Med 2005;4:135-43.

  1. Parkinson D. Golf-related head injuries. Surg Neurol 1999;51:580-1.
  2. United States Golf Association. Rules and decisions. Section I – etiquette; behavior on the course. Available at: http://www.usga.org/rules/rules-and-decisions.html#!etiquette; 2016. [accessed 29.11.16].
  3. Grimshaw PN, Burden AM. Case report: reduction of lower back pain in a professional golfer. Med Sci Sports Exerc 1999;32:1667-73.
  4. Parziale JR. Healthy swing: a golf rehabilitation model. Am J Phys Med Rehabil 2002;

81:498-501.