Golf is a popular sport worldwide, regardless of race, sex, age, or skill level (Cabri et al., 2009; McHardy et al., 2006; Sell et al., 2007). The global significance of golf was reinforced by this sport's inclusion in the 2016 Summer Olympics, the first time that golf was played at the Olympics since 1904 (Soligard et al., 2017).
There are many professional and amateur golfers in Korea. As of June 2017, the Korean Ladies Professional Golf Association (KLPGA) had 1,644 full members and 2,274 total members (KLPGA, 2017). Korean female professional golfers occupy more than half of the 15 top ranking in the Ladies Professional Golf Association (ROLEXRANKINGS, 2017). Unfortunately, the growing number of female golfers in Korea has been accompanied by a corresponding increase in golf-related injuries, many of which have been attributed to excessive training and competition beginning in childhood (Cabri et al., 2009; McGuffie et al., 1998; McLain and Reynolds, 1989).
According to epidemiological studies of the Olympic Games, golf was associated with a low injury risk-lower, for example, than BMX cycling or Taekwondo (Engebretsen et al., 2013; Grim et al., 2017; Junge et al., 2009; Soligard et al., 2017). However, golfers incur a large number of acute traumatic and overuse injuries, even though they are competing in a sport of noncontact with another player (Walsh et al., 2017).
Golf requires repetitive swinging in the same direction, and overuse of specific body parts because of excessive practice and competition can frequently result in inflammation and pain (Gosheger et al., 2003; McHardy et al., 2006). Although there have been many studies of injuries among professional and amateur golfers throughout the US and Europe, there exist few epidemiological studies of Asian professional golfers (McCarroll, 1996; McHardy et al., 2007; McHardy and Pollard, 2005). Preventing sports injuries and improving athletes' performance is an important goal of the International Olympic Committee (IOC) (Engebretsen et al., 2013; Soligard et al., 2015; Soligard et al., 2017). Epidemiological studies are necessary to understand the factors related to golfers' injuries and help in the development of programs that will prevent such injuries and enhance golf performance.
The purpose of the study sought to analyze the incidence, location, type, and mechanisms of injuries at the various levels of tournament play and to elucidate possible injury risk factors among Korean female professional golfers.
In total, 400 professional players took part in KLPGA tournaments during the 2015 and 2016 seasons, of which 363 golfers participated completely in this study. 119 golfers in Division I participated in this study, followed by 121 golfers in Division II and 123 golfers in Division III. The KLPGA tournaments were divided into three divisions. Division I, reserved for players with the highest ranking, held 31 tournaments per season in several different formats: three or four rounds of 18-hole stroke play (with only the top 60 players plus ties continuing to pay after the first two rounds) or gameplay. Divisions II and III had 19 and 16 tournament games per season, respectively, each of which consisted of two rounds of play (KLPGA, 2017). The study design was approved by the Yonsei University Institutional Review Board (IRB No. 7001988-201708-HR-245-04).
We administered four surveys during the two seasons (each May and November). After filling out their scorecard upon finishing the day's round, golfers completed the Yonsei Institute of Sports Science and Exercise Medicine Injury Surveillance System (YISSEM ISS) survey of golf-related injuries under the supervision of athletic trainers. During the 6 months between surveys, the golfers were asked to note any golf-related injuries so that they could be recorded in the next survey.
The 35-item YISSEM ISS questionnaire contains items from both the IOC and the United States National Collegiate Athletic Association (NCAA) Injury Surveillance System questionnaires (Dick et al., 2007; Engebretsen et al., 2012). It requests general information of relevance to female golfers: age, height, weight, body mass index (BMI), menstrual cycle, golf career, professional career, driving distance (i.e. official data by KLPGA), golf practice amount per day, and number of competitions during previous season (i.e. official data by KLPGA) (KLPGA, 2017). It also obtains information related to injuries (onset, acute or chronic, location, type, mechanisms, type of playing surface, and weather), and injury management and treatment questions (clinical exam, type of treatment and management, warmup, and stretching habits). Definition of injuries and illnesses were as new (i.e., pre-existing conditions were not recorded), or recurring musculoskeletal complaints, or other medical conditions (injuries) and or illnesses that occurred in competition and practice during the six months (Junge et al., 2009). Duplicate data on injuries and illnesses of a golfer were excluded. The YISSEM ISS questionnaire shows in Appendix 1.
We examined the impact of golf-related injury variables using univariate analysis and descriptive statistics. The injury rate was calculated per 1,000 athlete exposures (AEs) of practice or competition (game) (Soligard et al., 2017; Tuominen et al., 2017). The game AEs per golfer was calculated as 1 AEs per Day on the competition participated. The practice AEs per golfer was calculated by the number of rounding (9 or 18 holes) per week or, the number of practice golf swing (more than 1 box, assuming 100 balls per box) and or the number of physical training per day or week (Tuominen et al., 2017) (Refer to 7 in Appendix 1). Total AEs was added for 24 months period. Chi-square analysis was used to evaluate potential associations between injury information, injury management, and treatment at each level of the tournament. The analysis of risk factors for golf-related injuries applied a multivariate logistic regression model (Hosmer Jr et al., 2013). We calculated the odds ratios (OR) and the 95% confidence intervals (CI) to measure the strength of associations between each risk factor and injury information. All statistical analyses were performed using SPSS V.24.0 (IBM Corp, New York, USA). We regarded two-tailed p values of
Of the 400 Korean female professional golfers on tour during 2015 and 2016, overall 90.8% of golfers (n = 363) completed and returned their follow-up the YISSEM ISS questionnaire. 37 golfers were excluded from the study due to only one season attended or missing survey data, etc. The average age of total golfers was 22.3 years. On average height, weight and BMI of total golfers were 165.5 cm (SD 5.3), 59.7 kg (SD 6.7), and 21.9 kg/m2 (SD 6.7). Total 9.9 years (SD 3.5) of golfers was golf career and 4.7 years (SD 3.0) of a professional career. The average driving distance of total golfers was 236.3 yards (SD 14.3). The normal menstruations of total golfers were 292 and 56 of hypomenorrhea (Table 1).
Incidence of injury
A total of 510 injuries were recorded, of which injury rate of 8.5/1000AEs-games, and 3.3/1000AEs-practice (p
As noted above, Division I had 31 tournament games per year, of which 20 last for 3 days and 11 for 4 days. Divisions II and III had 19 and 16 2-day tournament games, respectively. A professional golfer requires 4-5 hour (h) to complete each round (i.e. 520 h in D I, 190 h in D II, and 160 h in D III per year, respectively). Division I golfers undergo approximately 6 h of golf training per competition day, division II golfers 7 h, and Division III golfers 7.5 h (i.e. golf training means a combination of warm-up, playing, post-round practice, etc.).
Location and type of injury
Overall, the most common injury location among KLPGA golfers was the upper extremities (40.7%), followed by the head and trunk (33.2%) and the lower extremities (26.1%) (Table 2). The relative prevalence of upper extremity injuries was greater in the lower divisions, especially Division III, whereas Division I had a higher percentage of lower extremity injuries. The shoulder/clavicle, wrist, lumbar spine/lower back, ankle, neck/cervical spine...