Physical Therapy in Sport 6 (2005) 122–130 www.elsevier.com/locate/yptsp
a,b
a,
a
c a
Faculty of Health Sciences, School of Physiotherapy, The University of Sydney, P.O. Box 170, Lidcombe, NSW 1825, Australia b
School of Physiotherapy and Exercise Science, Griffith University, Gold Coast Campus PMB 50, Gold Coast Mail Centre, Qld 4726, Australia c
St Vincent’s Hospital, Sydney, NSW, Australia
Received 27 September 2004; revised 12 May 2005; accepted 20 May 2005
Abstract
Objectives : Low back pain (LBP) is a common and disabling problem amongst golfers. Despite this, the risk factors for LBP in golfers have not been clearly established and therefore, optimal prevention strategies are not developed. This study was designed as a preliminary investigation of predictors for LBP in trainee professional golfers.
Design : Longitudinal prospective study.
Setting : Golf courses.
Participants : Trainee professional golfers ( N Z 14).
Main outcome measures : Potential risk factors included anthropometric variables, flexibility, muscle strength, and muscle endurance.
Associations were evaluated between these risk factors and reported episodes of LBP obtained from participants after every trainee match during one competition season.
Results : Golfers with a body mass index (BMI) !
25.7 kg/m
2 and those with a right side deficit of O 12.5 s on the side bridge endurance test reported more frequent episodes of moderate–severe LBP. Golfers with reduced hip flexor length more often reported that LBP affected their golf.
Conclusions : BMI, the side bridge endurance test, and hip flexor length were found to be significantly related to LBP amongst trainee professional golfers. Having optimal values on these variables may potentially prevent LBP arising from the repetitive biomechanical demands of the golf swing.
q
2005 Elsevier Ltd. All rights reserved.
Keywords: Low back pain; Golf; Body mass index; Muscular endurance tests
1. Introduction
According to data collected in 2002 by the Australian
Bureau of Statistics, more than 1 million Australians played golf in the preceding 12 months. Worldwide, a reported 55 million people play golf (
Farrally et al., 2003
). Although considered a relatively benign sport, low back pain (LBP) is common amongst both amateur and professional golfers, significantly affecting playing careers (
Batt, 1992; Gosheger, Liem, Ludwig, Greshake, & Winkelmann, 2003;
McCarroll, Rettig, & Shelbourne, 1990; Sugaya, Tsuchiya,
* Corresponding author. Tel.:
C
61 2 9351 9180, fax:
C
61 2 9351 9601.
E-mail address: k.refshauge@fhs.usyd.edu.au (K.M. Refshauge).
1466-853X/$ - see front matter q
2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2005.05.003
Moriya, Morgan, & Banks, 1999 ). For professional golfers,
LBP is the most frequently reported musculoskeletal injury and is thought to result from the repetitive, asymmetrical nature of the golf swing and frequent play and practice
(
Gosheger et al., 2003; Sugaya et al., 1999 ). There is limited
prospective research, however, linking specific physical risk factors and episodes of LBP in golfers. To date, no study has investigated the occurrence of, or risk factors for, LBP in trainee golf professionals. These elite golfers might be thought to be particularly at risk since they are training hard to become professional tour players, club professionals, or golf coaches.
Factors that have been suggested to contribute to LBP in golfers include poor endurance and strength of the trunk muscles (
Grimshaw & Burden, 2000; Horton, Lindsay, &
Macintosh, 2001; Pink, Jobe, Yocum, & Mottram, 1996;
Vad, Bhat, Basrai, Gebeth, Aspergen, & Andrews, 2004;

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 123
Fig. 1. The Biering-Sorensen test of trunk extensor endurance (
Biering-Sorensen, 1984 ).
Weishaupt, Obermuller, & Hofmann, 2000 ). However, the
only study examining trunk muscle endurance amongst golfers (
Suter & Lindsay, 2001 ) focussed on the association
between trunk extensor endurance and quadriceps muscle function. Whilst this study found that low-handicap golfers with chronic LBP and poor endurance on the Biering-
Sorensen test had significant inhibition of the knee extensors, and poor performance on the Biering-Sorensen test has been shown to predict occurrence of LBP in other populations (
Biering-Sorensen, 1984; Luoto, Heliovaara,
Hurri, & Alaranta, 1995 ), the relevance of trunk muscle
endurance to risk of LBP in golfers is unknown. The
Biering-Sorensen test (
Fig. 1
), and both the trunk flexor
endurance ( Fig. 2 ) and the side bridge endurance tests
(
Fig. 3 ) (
McGill, Childs, & Liebenson, 1999 ) all have high
reliability and would be simple to employ in the clinical examination of a golfer (
Latimer, Maher, Refshauge, &
Colaco, 1999; McGill et al., 1999
). Given the asymmetrical nature of the golf swing, the side bridge endurance test, which is suggested to optimally challenge the quadratus lumborum and muscles of the anterolateral trunk wall
(
McGill et al., 1999 ), may also detect unilateral differences
in trunk muscle endurance relevant to golfers.
With regard to strength, golfers have been found to have greater trunk extensor strength than controls (
Weishaupt et al., 2000
). Further, various strengthening exercises for the trunk muscles have been advocated for golfers, in part to improve performance but also with the aim of reducing the
risk of LBP ( Hellstrom, 2002; Pink, Perry, & Jobe, 1993;
Pink et al., 1996
). Although studies have reported positive outcomes for strength training for golfers (
Fletcher &
Hartwell, 2004; Grimshaw, Giles, Tong, & Grimmer, 2002;
Hetu, Christie, & Faigenbaum, 1998
), these studies did not examine the risk of LBP.
Golfers are a unique population, employing very specific movements, some through large ranges of motion, to achieve positions considered optimal for generating a consistent, powerful swing. They also sustain positions for prolonged periods during practice (e.g. sustained lumbar spine flexion during putting). The repetitive and asymmetrical motion of the golf swing is thought to result in specific range of motion deficits (
Vad et al., 2004 ). Although
exercises to improve range of motion are commonly recommended to golfers, it is yet to be clearly demonstrated
that such exercise programs prevent injury ( Sherman &
Finch, 2000 ).
Although poor conditioning (
McCarroll, 1996; Pink et al., 1996
) has been suggested to contribute to LBP in golfers, the relationship between general fitness and risk of
LBP has likewise not been clearly evaluated. Similarly, the relationship between body mass index (BMI) and LBP remains unclear for both non-golfing populations (e.g.
Hellsing & Bryngelsson, 2000; Leboeuf-Yde, Kyvik, &
Bruun, 1999; Mellin, 1987 ) and golfers ( Gosheger et al.,
2003; The´riault & Lachance, 1998
). Finally, previous LBP has been shown to be a risk factor for future LBP in novice golfers and other athletic populations (
Burdorf, van der
Steenhoven, & Tromp-Klaren, 1996; Greene, Cholewicki,
Galloway, Nguyen, & Radebold, 2001 ). Because no
prospective study has investigated these risk factors in elite golfers, this preliminary study aimed to determine whether selected musculoskeletal tests of trunk muscle endurance and strength, range of motion and anthropometric variables predicted occurrence and severity of LBP in a group of trainee professional golfers.
Fig. 2. Trunk flexor endurance test (
McGill et al., 1999
).

124 K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130
Fig. 3. Side bridge endurance test (
McGill et al., 1999 ).
2. Methods
2.1. Subjects
Eighteen trainee professional golfers enrolled in the
Queensland (Australia) division of the Professional Golfer’s
Association (PGA) and who lived in the metropolitan region volunteered to participate in the study. In this 3-year program, trainees must play at an elite level, attaining an adjusted handicap average on their best 80% of scores of
C
4 strokes or less at the end of their third year.
All subjects were active, male, and aged between 18 and
35 years (
Table 1 ). Sixteen subjects were right handed, 12
were in the first year of the traineeship, 2 in second year and
4 subjects were in the third year of the traineeship. Sixteen subjects reported having previous episodes of LBP. To identify subjects at risk from exercise, the Modified
Physical Activity Readiness questionnaire ( Kenney, Humphrey, Bryant, & Mahler, 1995 ) was administered but none
of the subjects were excluded on this basis.
2.2. Testers
All measurements were performed according to a standard protocol by an experienced manipulative physiotherapist and an exercise scientist, who were blinded to current or previous LBP status.
2.3. Protocol
Testing took place 1 week prior to the first trainee tournament of the year at a local golf course, using portable equipment. Subjects were then asked to report occurrence and severity of LBP after each traineeship or
PGA-sanctioned tournament. Since all trainee professionals are required to play at least 15 rounds of golf, with a total of 540 holes to successfully complete their traineeship year, subjects submitted pain reports on at least 15 occasions over their 10-month competition season.
2.4. Variables
Anthropometric measures included height, weight,
BMI, upper body length, and upper body mass
(
Table 1 ). Upper body length was measured from
subject’s anterior superior iliac spine (ASIS) to the crown of their head. Upper body mass was measured with subjects in prone lying with their ASIS on the edge of the plinth so that the upper body was off the bed.
Subjects were instructed to put their palms flat on a set of electronic scales placed on the floor and the weight of their body through their hands.
Prior to testing, current level of physical activity was assessed with the Physical Activity and Health Related
Issues Questionnaire devised by
National Heart Foundation (1990, p.
122)
and modified by
Hunter,
Thompson, and Adams (2000)
. This questionnaire comprises a six-point scale, where 1 denotes no participation in regular exercise, and 6 denotes R 5 sessions/week of high intensity exercise of O 20 min duration (
Table 1 ). Strength of the trunk and hip
extensors, trunk endurance and hip and trunk flexibility were measured. The order of tests was randomised.
Table 1
Subject’s characteristics. Mean (SD) and range for age, weight, height, upper body mass, upper body length, body mass index (BMI), and Self
Reported Physical Activity Rating (SRPAR)
Variable
Age (years)
Weight (kg)
Height (cm)
Upper body mass a
Upper body length b
(kg)
(cm)
BMI (kg/m
2
)
SRPAR c
Mean (SD)
23.7 (4.4)
81.0 (13.2)
182.7 (7.3)
34.8 (4.9)
79.1 (2.0)
24.2 (3.3)
4.2 (1.2)
Range
18–35
61–112
167.5–193.6
25–45
76–83
20–31
3–6 a
Measured using electronic scales (subject prone with anterior superior iliac spine at edge of plinth).
b
Measured from anterior superior iliac spine to crown of head.
c
Self-reported physical activity rating (scored from 1 to 6).

2.4.1. Endurance tests
Subjects performed three trunk muscle endurance tests.
Trunk extensor endurance
Sorensen protocol (
(1999) . Subjects lay prone with their lower body fixed to a
long as possible.
The endurance for the
( described by
Fig. 2
Fig. 1
K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 was measured using the Biering-
) as described by
side bridge endurance
) were conducted and measured as
side bridge endurance
(
Fig. 3
McGill et al. (1999)
) and
Latimer et al.
plinth by three seat belts and their upper body resting on a chair. Subjects were asked to cross their arms over the chest, lift the upper body and maintain a horizontal position as trunk flexor
. The starting position
test involved subjects lying on their side, resting on their forearm, with the elbow joint flexed to 90 8 . The other arm was positioned across the chest and legs were extended. Subjects were instructed to lift the hip off the bed and maintain a straight line with the whole body (
McGill et al., 1999
).
For trunk flexor endurance , subjects were positioned on a plinth with their back resting against a wedge that maintained 60 8 flexion from the horizontal. Knees were flexed to 90 8 and the feet supported on the plinth, secured with a seat belt (
Fig. 2
). In the present study, a universal goniometer, centred over the greater trochanter and with one arm placed along the line of the femur and the other placed on the lateral chest wall, was used to determine whether subjects deviated from this position. The test was terminated if subjects were unable to maintain neutral trunk position.
For all endurance tests, subjects were encouraged to hold their position until fatigue, and were given feedback if they deviated from the test position. Tests were terminated if subjects could not maintain the position, if there were any obvious signs of fatigue or significant increase in pain or other symptoms. Subjects were rested for at least 10 min between endurance tests.
2.5. Low back pain reports
Subjects were asked to report any episodes of LBP since playing their last trainee match and to record whether it affected their golf game (
Table 2
). The severity of any pain was indicated by marking the most appropriate descriptor on the form—‘none, mild, moderate or severe’. Detailed instructions for completing the questions were provided at the initial testing session and subjects were given opportunity to ask questions. Reports were collected in sealed envelopes by officials from the PGA attending the trainee matches or by one of the researchers (KE).
Thereafter telephone contact was used to maintain regular reporting.
The University of Sydney Human Research Ethics
Committee approved the study protocol and subjects gave consent prior to participation.
125 test protocol adopted by
Harvey (1998)
. Subjects were also asked to perform a standardised sit and reach test (
Keogh,
1999
).
Lumbar spine flexion and extension range of motion were measured using the modified–modified Schober method
(
Williams, Binkley, Bloch, Goldsmith, & Minuk, 1993 ).
Trunk side bending range was measured using a motion-
fingertip to floor method ( Maher, Latimer, & Refshauge,
2000
). In order to measure trunk rotation in standing, subjects stood on a line with their feet comfortably apart, equidistant from the centre holding a bar on their shoulders.
They were then instructed to rotate as far as possible to one side, keeping their knees straight and without moving their feet. A plumb bob was then dropped, a mark made and degrees of rotation were measured using a goniometer. The reliability of this test was examined beforehand and found to be high with ICC
(2,1) Z
0.81.
2.4.2. Strength tests
Maximum hip and trunk extensor strengths were measured in the present study.
Hip extensor strength was measured using a hand-held dynamometer (Powertrak) with subjects in prone lying, a procedure previously shown to have good reliability (
Bohannon, 1986 ).
Trunk extensor strength was measured with subjects positioned in long sitting, pulling against a strain gauge device. The reliability of this test was examined beforehand and found to be excellent (ICC
(2,1)
Z
0.91). For each strength test, subjects performed three maximal voluntary contractions (MVC) and the highest force was recorded.
2.4.3. Flexibility tests
For each flexibility test, subjects were given one practice attempt, with feedback as necessary. The active knee extension test as described by
Gabbe, Bennell, Wajswelner, and Finch (2004)
was used to measure hamstrings length as these researchers found this test to have excellent reliability.
Hip flexor length was measured using the modified Thomas
2.6. Data analysis
To examine the relationship between the musculoskeletal/anthropometric tests and LBP, Pearson’s product moment correlation coefficient ( r ) was calculated between these variables and subjects’ responses to each of the LBP
Table 2
Questions regarding LBP which were completed by the trainee golf professionals after each compulsory PGA-sanctioned golf tournament
1.
2.
3.
4.
5.
6.
Have you had any low back pain since your last trainee match?
What was the average severity of your low back pain since your last trainee match?
Did you have any leg pain associated with your low back pain?
Have you had any low back pain whilst playing golf or whilst practicing since your last trainee match?
Has your low back pain affected your golf game at all since your last trainee match?
Has your low back pain stopped you from playing golf or practicing since your last trainee match?

126 K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 questions. Independent samples tivity —(1, specificity ) ( t -tests were conducted to compare the means for selected variables for subjects who experienced LBP with those who did not. For significant predictors, optimal cut-off points on the ROC curve were determined using Youden’s index, calculated as
Biggerstaff, 2000
sensi-
). Analysis was conducted using SPSS-Windows (Version 10.0.5).
3. Results of no or mild LBP were grouped together and considered the ‘no LBP group’. Those subjects reporting moderate or severe LBP were grouped together and were considered the ‘LBP group’. This grouping was used to conduct independent samples t -tests on the predictor variables and the results of these are presented in
Table 3 . Next, the percentage of time over the whole
10-month tournament period that subjects responded
‘moderate–severe’ for the relevant questions (range,
6–35%) was used to measure the severity of the LBP problem and was correlated with each of the test variables.
Of the 18 subjects who commenced, 14 subjects completed the reporting requirements of the study. This sample size was sufficient to give moderate power ( for correlation values for correlation values
O 0.62 and adequate power (
O 0.54 (
Cohen, 2000
O
O
60%)
50%)
). Correlation
values below 0.50 were not considered to be strong enough relationships with LBP to be worthwhile detecting as significant.
3.1. Summary of reported LBP
Over the study period, 14 subjects were questioned about
LBP on a total of 267 occasions. Because subjects played for different amounts of time, the range was from 15 to 31 occasions per subject. During the study, only one subject did not experience any episodes of LBP. More than half (57.1%) reported at least one episode of moderate or severe LBP,
28.4% reported moderate or severe leg pain associated with
LBP, 35.7% reported that LBP had moderately or severely affected their golf on at least one occasion, and six subjects
(42.9%) had to stop playing golf on one occasion because of
LBP. Only two subjects reported that LBP had never interfered with their golf during the 10-month period.
Further analyses were conducted. Firstly, reports of
LBP were considered as dichotomous data and responses
3.1.1. Relationship of test variables to LBP
Three variables were found to be significantly correlated with subjects’ responses: BMI, asymmetry on the side bridge endurance test, and hip flexor length.
BMI was significantly negatively correlated with percentage of reports of moderate–severe LBP
( r
Z K
0.67; p
Z
0.01).
Likewise, the magnitude of the difference between left and right side bridge performance (left minus right holding time) was significantly correlated with reported LBP
( r
Z
0.59, p
Z
0.03). That is, the greater the left relative to right endurance holding time, the higher the frequency of reported LBP.
Finally, hip flexor length was significantly and negatively correlated with perception of LBP affecting golf play or practice ( r
Z K
0.57, p
Z
0.03). No other anthropometric or flexibility test was significantly correlated with reports of LBP.
There was no significant relationship found between performance in trunk extensor or flexor endurance tests and reported LBP, or between the ratio of trunk flexor to extensor performance and reported LBP or previous history of LBP. Hip and trunk extensor strengths were not significantly correlated with any of the pain responses.
Table 3
Means (SD) of selected test variables for groups with and without moderate–severe LBP
Variables
BMI (kg/m
2
)
Flexor endurance (s)
Side bridge diff a
(s)
Biering-Sorensen (s)
Back extensor MVC (kg)
Right hip MVC (kg)
Left hip MVC (kg)
Right hip flexor length (degrees)
Left hip flexor length (degrees)
Right hamstring length (degrees)
Left hamstring length (degrees)
Right standing rotation (degrees)
Left standing rotation (degrees)
Sit and reach (cm)
Self-reported fitness scores (0–6)
Mean (SD)
Subjects with LBP ( n
Z
8)
23.4 (2.2)
166.5 (48.9)
K
19.3 (33.3)
100.6 (42.3)
158.2 (23.8)
157.7 (37.7)
153.4 (34.9)
16.5 (33.8)
11.8 (28.1)
158.1 (16.5)
156.1 (15.5)
115.8 (21.0)
113.9 (16.1)
K
1.9 (11.7)
4.3 (1.2)
Subjects without LBP ( n
Z
6)
27.3 (3.2)
268.5 (147.6)
4.6 (13.9)
101 (55.4)
168.0 (11.0)
162.0 (20.1)
151.4 (22.7)
9.5 (33.5)
9.2 (32.3)
152.3 (14.1)
153.5 (5.9)
113.3 (18.4)
116.8 (17.2)
K
0.58 (13.3)
4.3 (1.2) a
Side bridge endurance difference (right side bridge minus left side bridge holding time).
Significance, p
0.70
0.89
0.50
0.70
0.83
0.75
0.85
0.90
0.02
0.09
0.16
0.99
0.37
0.82
0.91

K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 127
Table 4
Sensitivity (Sn), specificity (Sp), and Youden’s index (YI) for body mass index (BMI), side bridge endurance (right–left difference), and hip flexor length
BMI value kg/m
20.6
21.7
21.9
22.25
22.9
24.35
2
Sn
1.00
1.00
0.83
0.83
0.83
0.83
Sp
0
0.13
0.13
0.38
0.63
0.75
YI
0
0.13
K
0.04
0.21
0.46
0.58
Side bridge endurance difference s
K
62
K
54
K
46.5
K
37.5
K
25
Sn
1.00
1.00
1.00
1.00
1.00
Sp
0.00
0.13
0.25
0.38
0.50
YI
0.00
0.13
0.25
0.38
0.50
Hip flexor length deg
K
36.5
K
33
K
28
K
25.25
K
21.25
Sn
1.00
0.89
0.89
0.89
0.89
Sp
0.00
0.00
0.20
0.40
0.60
YI
0.00
K
0.11
0.09
0.29
0.49
K
12.5
1.00
0.63
0.63
5.25
0.89
0.80
0.69
25.7
0.83
0.88
0.71
26.75
27.75
28.3
28.65
29.85
32
0.67
0.50
0.50
0.33
0.17
0.00
0.88
0.88
1
1
1
1
0.54
0.38
0.50
0.33
0.17
0
K
2
3.5
11
21.5
31.5
36
0.40
0.40
0.20
0.20
0.00
0.00
0.63
0.75
0.75
0.88
0.88
1.00
0.03
0.15
K
0.05
0.08
K
0.13
0.00
29
30.25
30.75
31.5
32.25
33.75
37.5
41.25
43.5
0.78
0.67
0.56
0.44
0.33
0.22
0.11
0.11
0.00
0.80
0.80
0.80
0.80
0.80
0.80
0.80
1.00
1.00
0.58
0.47
0.36
0.24
0.13
0.02
K
0.09
0.11
0.00
3.2. Predictive ability of the variables
Variables that were significantly associated with subjects’ responses were further analysed using ROC curves to determine relevant cut-offs for clinical recommendations.
Youden’s index was calculated for BMI, side bridge
endurance difference and hip flexor length ( Table 4 ).
Having a BMI of !
25.7 kg/m
2 or a right side deficit of
O 12.5 s were predictors of reports of moderate–severe LBP and having hip flexor tightness of O 5 8 predicted reports of
LBP affecting subject’s golf game or practice.
4. Discussion
This preliminary study is the first to investigate LBP in trainee professional golfers, a group of young elite golfers.
These results suggest that LBP is a significant problem for this specific group, potentially impacting on their ability to pursue their chosen career. More than half of the study group (57.1%) experienced at least one episode of LBP during the 10-month competition season and over one-third
(35.7%) reported at least one occasion where LBP had affected their golf. Only two subjects reported that LBP had never interfered with their golf during the 10-month period, whereas six people (42.9%) reported that they had to stop playing golf because of LBP. Previous studies have reported that LBP is the most common musculoskeletal injury experienced by professional golfers, possibly due to
repetitive play and practice ( Gosheger et al., 2003;
McCarroll & Gioe, 1982; Sugaya et al., 1999
). Although no formal attempt was made to record frequency of practice undertaken, over the course of the study all subjects completed at least 15 rounds of 36 holes of golf and it is reasonable to assume that they would play additional rounds and practise for a considerable amount of time in order to retain the low scoring average required to successfully complete a traineeship year. Overuse may therefore be a significant contributing factor to the aetiology of LBP in trainee golf professionals.
The strongest predictor of LBP was BMI, which was inversely related to reports of LBP. That is, relatively tall, slender golfers were more likely to experience LBP than relatively short, heavy golfers. These results are consistent with data reported by
Lindsay and Horton (2002)
where the six golfers who reported always experiencing LBP when playing or practising had a BMI of 24.4 kg/m
2 compared with a BMI of 27.7 kg/m
2 for the six golfers who reported never experiencing LBP.
Gosheger et al. (2003)
also found that amongst amateur and professional golfers, a high BMI was not associated with more golf injuries although golfers with a BMI of O 25 kg/m
2 were more likely to report LBP unrelated to golf. The BMI data for the professionals was not separately reported and the mean age of their population was 46.2
G
17.3 years whereas the present findings were obtained from an elite group some 20 years younger.
The relationship between high BMI and fewer episodes of LBP in the present study was not due to trainee golfers with high BMI being stronger because BMI was not associated with performance on either of the strength tests. One possibility, then, is that simply having a larger overall mass provides a buffer against back injury when playing golf. According to results obtained here, tall golfers, who may be able to produce optimal club head velocities through a long swing arc, also need to have larger muscle mass or a heavy build in order to protect their lumbar spine from injury. Another possibility could be that tall, slender golfers achieved greater ranges of movement during the swing, thereby potentially increasing the loads on their lumbar spine. Shorter, heavier golfers may be able to

128 K. Evans et al. / Physical Therapy in Sport 6 (2005) 122–130 achieve optimal swing mechanics with minimal force on the lumbar spine through efficient momentum transfer (
Okuda,
Armstrong, Tsunezumi, & Yoshiike, 2002 ). These alterna-
tive accounts require further examination.
Performance on the side bridge test was associated with reports of LBP but there was no association between the tests of trunk extensor or flexor endurance and LBP.
Subjects whose left side bridge endurance time was greater than the right by O 12.5 s were more likely to report episodes of LBP in the subsequent 10-month period. The relevance of this test as a predictor for LBP in golfers may be related to the asymmetrical nature of the golf swing, which subjects the lumbar spine to extremes of asymmetric motion and rapid and complex loads, particularly during the downswing (
Hosea, Gatt, Galli, Langrana, & Zawadsky,
1990; Sugaya et al., 1999 ). For example, in a right-handed
golfer, trunk motion occurring during the downswing and acceleration phases involves a combination of left axial rotation and right lateral bending. The right abdominal oblique muscle has been found to be particularly active during the acceleration phase of the swing on EMG (
Hosea
& Gatt, 1996; Watkins, Uppal, Perry, Pink, & Dinsay, 1996
) and
Sugaya et al. (1999)
reported that right-handed professional golfers were more likely to experience pain on the right hand side of the lumbar spine. It has been suggested that golfers, like other athletes, exhibit adaptive changes that have developed in response to the demands of
their sport ( Vad et al., 2004 ) and therefore golfers who play
more frequently may require better endurance of the muscles on the dominant anterolateral aspect of the trunk to produce a smooth, consistent, powerful swing in an injury-free manner. Alternatively,
Lindsay and Horton
(2002)
found that golfers with LBP had greater left side bend during the backswing than golfers without LBP.
Golfers with LBP who were consistently producing greater left side bend during the swing may therefore develop better endurance of the trunk muscles producing this motion, reflected in better performance on the left side bridge endurance test. However, in the present study, there were two left-handed golfers. One of these could not complete a right side bridge endurance test due to an acute shoulder injury so was not included in the data analysis. The other left-hander had two occasions of LBP and on one occasion, had to stop playing golf due to LBP. This subject’s left and right side bridge holding time was 96 and 35 s, respectively, data which implies that his dominant side had better endurance. Further analysis could not be undertaken to examine handedness effects because there were too few subjects for sub-group analysis. Subsequent studies with larger populations are required to clarify these findings.
Consistent with previous findings (e.g.
Holmstrom,
Moritz, & Andersson, 1992 ), trunk extensor strength was
not correlated with trunk muscle endurance and was only weakly inversely correlated with reports of LBP. Trunk extensor strength may be important for improving driving
distance and clubhead speed ( Fletcher & Hartwell, 2004
) but good trunk extensor strength has not been clearly shown to prevent LBP. In the present study, only trunk and hip extensor strength was examined. Whether the strength of other muscle groups important in the golf swing
(e.g. abdominals) relates to reports of LBP should be evaluated in future studies.
A measure of the impact of LBP experienced by trainee professional golfers is the effect LBP has on their golf game or practice. During the 10-month period, only two subjects reported that LBP had never interfered with their golf game and over one-third (35.7%) reported that LBP had affected their golf on at least one occasion. Six people (42.9%) had to stop playing golf because of LBP. Of the variables tested in this study, golfers with relatively shorter hip flexors were more likely to report that they felt LBP had affected their golf game or practice.
Vad et al. (2004)
found that professional golfers who had experienced LBP in the previous 12 months had reduced range of internal rotation of the lead hip, FABERE’s distance and lumbar spine extension range compared with asymptomatic golfers. The present study did not examine hip internal rotation range or
FABERE’s test, but found no relationship between lumbar spine range of motion and future episodes of LBP.
This study has clinical implications for therapists working with golfers whose aim is to minimise risk of
LBP. First, an above-average BMI seems to be helpful in preventing LBP. As there are negative health consequences associated with increasing percent body fat, the implication here is for golfers with a BMI below 25 kg/m
2 to use resistance exercises to add more overall muscle mass.
Second, if their left side has better endurance, to improve right side bridge endurance, by training in the manner of the test (
Axler & McGill, 1997; McGill, 1998 ). Finally, we
found that tight hip flexors were not associated with frequency of LBP episodes, but were related to perceiving that LBP affected golf performance. Intervention to increase hip flexor length may therefore be useful and at worst the consequences of improving hip flexor length are benign.
Fradkin, Sherman, and Finch (2004)
found a significant increase in clubhead speed for golfers who underwent a
5-week warm up conditioning program. The specific stretches were not outlined but data from the present study suggest that incorporating a hip flexor stretch into such a routine may also be beneficial.
5. Conclusion
LBP is a significant problem for trainee professional golfers. In this prospective study, over half experienced at least one episode of moderate–severe LBP during the
10-month period and 35.7% reported at least one occasion where LBP had affected their golf. Of the measures taken, having a normal or low BMI and a right side deficit on the side bridge endurance test independently predicted future episodes of LBP, with BMI being the strongest predictor.

Golfers with tight hip flexors were more likely to report that
LBP affected their golf game or practice. The findings here may all be explained as consequences of the repetitive biomechanical demands of the golf swing and although further research is needed, current data support the inclusion of these tests in a musculoskeletal examination of a trainee professional golfer. The other variables examined in this study, however, cannot be excluded as being unrelated to
LBP in golfers without further studies involving larger groups.
Acknowledgements
The authors wish to thank the Australian Professional
Golfer’s Association of Australia for their assistance with this project.
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