Golf and your Feet – Part 2

Common Foot Injuries in Golf:
In my previous article, Golf and Your Feet Part 1, I spoke about how your feet affect the mechanics of golf. In Part 2, I want to highlight common golf related injuries podiatrists will see. Golfers may not realize the amount of time they spend on their feet while playing 18 holes of golf. The average round of 18 holes totals several miles of walking. It’s no surprise this can lead to foot and ankle pain. Many golf related conditions involving the feet can be due to overuse injuries. They are caused by the recurring motion of swinging the golf club in the same or similar form with each swing. Listed below are common foot problems associated with golf and their recommended remedies. Often, adjustments you can make with your feet can address many of these problems.

1. Neuromas – Neuromas are a thickening or enlargement of nerve tissue. The most common neuroma in the foot is a Morton’s neuroma, which occurs between the third and fourth toes. It can occur in other locations too. A neuroma is usually the result of compression and irritation of the nerve. This compression creates enlargement of the nerve, eventually leading to permanent nerve damage. In golf, as your body transfers its weight from one foot to the other while swinging the club, the nerve can become compressed and cause pain. The irritation of the nerve is more noticeable on longer shots, such as a drive, than on shorter shots, like putts.

Common symptoms of neuromas are:
• Tingling, burning, or numbness starting in the front of the foot and shooting pain into the toes
• Pain in the ball of the foot
• A feeling that something is inside the ball of the foot
• A feeling that there is something in the shoe or the feeling a sock is bunched up underneath the toes

Treatment options for neuromas consist of NSAIDs, prednisone taper, steroid injection, alcohol sclerosing injections, orthotics/inserts, and stiffer shoes. When conservative measures fail, surgery may be considered.

Many of the golf-related neuromas may resolve with a change in stance. By adjusting the mechanics of the swing, less irritation can be experienced on the nerve. The adjustment consists of turning the front foot inward 45 degrees. This shift in the foot at the beginning of the swing affects the position of the foot at the end of the swing to decrease nerve irritation.

2. Plantar fasciitis/Achilles tendonitis/Heel pain
Plantar fasciitis is a type of heel pain that will occur at the bottom and/or arch of the foot. The pain occurs from an inflammation of the band of tissue that connects the bones in the ball of your foot to the heel bone. It can be a very sharp pain that is typically worse after periods of inactivity.

The first few steps are very painful, and the pain can ease with walking. There is often a tightness in the arch too. Achilles tendonitis is heel pain that occurs to the back of the heel. This also can feel like a sharp pain and tightness to the back of the heel after periods of inactivity. When you walk on uneven surfaces, such as the golf course, the foot needs to accommodate and balance the feet. This can make heel pain worse. Plantar fasciitis and Achilles tendonitis can occur together. These types of heel pain can make it difficult to maintain a solid stance during the golf swing.

Treatment options include supportive golf shoes, orthotic/shoe inserts, stretching exercises, icing and medications to decrease inflammation.

Wearing a stable golf shoe should help to balance and support your feet. This can help to improve your posture and weight distribution during your swing. Twisting your foot inward can irritate and inflame the plantar fascia ligament. Consult with a golf pro who can help you to practice proper form. Using a golf cart to decrease walking also helps with heel pain.

3. Subungual hematoma (Blood under the nail)
Blood can form under a nail when excessive repetitive pressure is placed on the big toe during the golf swing. This usually happens at the end of the follow through when the big toe slides forward and hits the top and end of the shoe in the dominant foot. The recurring trauma with each swing will damage the big toenail and underlying tissue allowing blood to get trapped underneath the nail. The blood is trapped underneath the nail and pressure builds up. This can be very painful due to the pressure the blood exerts on the nail bed. The nail coloration also becomes altered with the blood underneath it. Often, the skin surrounding the nail will be red and swollen. Occasionally, the blood will drain from the end of the nail. This will relieve some of the pressure and pain, however, the nail itself will not reattach to the tissues.

Treatment options for a subungual hematoma may include drainage of the blood under the nail, and possible removal of the nail plate. If the nail is removed, it will grow back.

Since this injury occurs during the golf swing, the swing can be modified to decrease nail irritation and possibly stop injury from reoccurring. This is accomplished by moving the back foot slightly away from the target. This decreases the pressure to the end of the toe during the follow through. The pressure gets shifted to the inside of the foot rather than focused on the toe region.

4. Extensor tendonitis – aka Golf Cart Tendonitis
The Extensor tendons are located on top of the foot and ankle. They work to raise your foot and toes upwards at your ankle. Extensor tendinitis typically occurs only in the right foot of the driver of the golf cart. There are two sections to the brake on a golf cart. The top piece needs to be pressed firmly downward when engaging the brake. With repetitive pressing down of the parking brake, the tendons on top of the foot gets stretched and can be irritated if the brake is used excessively. This can be seen on regular course terrain, but often more frequently happening after playing rounds on hilly golf courses.

Symptoms of extensor tendonitis include generalized pain to the top of the foot. There may be some swelling to the top of the foot also. Pain will be present with walking or bending of the foot.

This condition can be treated with medications to diminish inflammation, ice, stiff shoes and decrease irritation to the tendons. Ultimately, making modifications to applying the parking brake while driving the cart may reduce recurrence of this condition. Patients are encouraged to alternate using the left and right foot on the brake. Using the back of the foot (heel) to engage the brake can also help to decrease the irritation of the tendons. Park the golf cart in areas of flat ground since the force required to push down the parking brake on a hill is greater. Another option is to rotate driving responsibilities with your partner every other hole.

5. Metatarsalgia – Metatarsalgia is a general term used to describe pain across the ball of the foot. Excessive pressure of a golf spike under the ball of the foot can cause this type of pain. It will be localized to the area underneath the problematic spike.

Removal of a spike or purchasing golf shoes that allow multiple spike placement helps with this condition. Padding the area and orthotics/inserts have also been successfully utilized to decrease the pain associated with metatarsalgia.

6. Blisters – Blisters are a frequent problem at the end of a round of golf due to the rubbing and friction that occurs during play. It is recommended not to pop the blister. Apply a well-padded bandage. If the blister has already popped, apply an antibiotic cream and bandage for healing. If the blister is too large and/or causes pain, a visit to the podiatrist is warranted. Proper fitting of the golf shoes is key to minimize this problem. Also, always wears socks. There are anti-friction socks, pads, and balms available over the counter for those prone to forming blisters.

It is best to know the underlying cause of your foot pain. By seeing a Podiatrist, they can evaluate your symptoms and institute a treatment plan to resolve your foot pain. Remember foot pain is not normal. Don’t put up with foot pain – get it fixed so you can keep on playing and enjoying your rounds of golf.

I can’t promise to bring your handicap down, but at least you won’t be able to blame foot pain as your handicap!