To Repair or Replace?

Advances in orthopedics can answer that question sooner than you think.

Jon Rizzi

The golf swing puts unnatural stress on our backs, knees, elbows, hips and shoulders. Pain in these areas can keep you from enjoying more than just golf. As the expertise to treat these injuries has advanced with stem cells and plasma treatments, so has the ability of orthopedists to replace worn-out joints with new ones.

All doctors interviewed here cite the benefits of rest, non-steroidal anti-inflammatories like Aleve and specific exercises as first steps in pain reduction. Cortisone injections can help as well—but in moderation; any more than one every four to six months runs the risk of damaging muscle fibers. Avoid opiates, as they don’t treat symptoms and can be addictive.

X-Rays of a knee replacement (top) and cervical disk replacement (above)

BACK
“Lumbar pathology is the most common spine injury among golfers,” Gary Ghiselli, M.D., of Denver Spine Surgeons says, referring to the lower back. He cites the modern swing as one of the chief culprits. “Unlike the classic swing, players now keep their left heel on the ground, torquing their lower back on the backswing and hyperextending it on the follow-through.”

It’s no wonder that the most famous modern swinger, Tiger Woods, has had multiple microdiscectomies to relieve pain in his lumbar region. Woods, however, did not go as far as Retief Goosen. In 2012, the two-time U.S. Open champion had his degenerating L3‑L4 disk replaced with one made from titanium.

According to Dr. Ghiselli, disk replacements in that region of the back have not been as common or as efficacious as microdecompressions and microdiscect-omies have been. These minimally invasive surgeries help decom-press the herniated disks and structures that pressure the nerve.

Another option is spinal fusion, wherein a doctor grafts two vertebral elements together to create a single immobile bone, thus stopping motion that generates pain. Spinal fusions traditionally require inserting large pedicle screws, which in and of themselves can cause chronic pain or problems at other levels. Dr. Ghiselli says he’s had greater success in recent  years with interspinous stabilization, an outpatient procedure that promotes greater vertebral stability through the use of a small titanium clamp instead of screws.

Retief Goosen had L3-L4 disk replacement

While the lumbar region presents the most common problem for golfers, damage in the cervical spine (the seven vertebrae in your neck) can also cause issues.

Dr. Ghiselli tells the story of a famous orthopedic surgeon diagnosed with a herniated cervical disk that left his left hand so weak he found it difficult to operate.

“He was conflicted about having the procedure done to relieve it,” Dr. Ghiselli explains. Was he worried about the success rate? “Not at all. He said he was about to retire and his new relaxed grip was doing wonders for his golf game!”

Unlike lumbar disk replacement, cervical disk replacement is becoming a more accepted procedure. “The one- and two-level replacements are pretty phen-omenal,” Dr. Ghiselli reports. “They’re FDA-approved and recent literature shows they may be superior to a fusion. That’s exciting!”

KNEES and HIPS
With a success rate between 90 and 95 percent, hip and replacements among older golfers have become as common as arthritis—which happens to be the chief reason to have them. The incidence of these replacements has increased more than 50 percent since the beginning of the century.

Even with all that surgical success, Joseph Assini, M.D. of Orthopaedic Physicians of Colorado, recommends patients with pain first try glucosamine supplements and viscosupplementation (also known as “rooster comb” injections) before going under the knife.

Minimally invasive arthroscopy works for meniscal tears but not for arthritic knees.

Fred Funk (knee) and Hal Sutton (hip) have had replacements

But if a partial knee or total hip re-placement becomes unavoidable, Dr. Assini’s patients have MAKOPlasty, a procedure, he says, that “has revolutionized the way implants are put into the body.”

MAKOplasty enables surgeons like Dr. Assini to plan partial knee or total hip replacement procedures by using three-dimensional computer imaging based on a CT scan. This allows them to determine optimal implant size, position, and alignment for each individual patient, and to map out accurately the areas of bone they want to remove.

“We expose degenerated part of bone, map it out with a GPS-type system and match it with what CT scan shows us right in the operating room,” says Dr. Assini. “Then the robotic arm system provides visual, auditory and tactile control—where the implant should be placed and how much tension should be used. It only allows us to cut within the affected area. It’s like a computer game. I look at the screen the whole time.”

Robotic-assisted MAKOplasty

MAKOplasty removes risk of misalignment. “On hip replacements, the precision of cup placement and accurate leg-length restoration is unmatched,” says Dr. Assini. 

The success of MAKOplasty or any joint replacement depends on how well the implant incorporates into the bone. That takes time, so doctors recommend a minimum of four weeks before heading out to the golf course.

ELBOW and SHOULDER
The distinction between “tennis elbow” and “golfer’s elbow” isn’t sport-specific. “I see as many golfers with tennis elbow as with golfer’s elbow,” says Armodios “Hatz” Hatzidakis, M.D., of Western Orthopaedics in Denver. Both indicate epicondyle (the tendons that attach from the wrist to the elbow) inflammation that results from overuse.

The difference is which side of the elbow hurts (“tennis” affects the lateral, or outside; “golfer’s” affects the medial, or inside). In the case of golf, epicondylitis usually results from the wrist absorbing the vibratory force of a stiff club hitting balls (or a root or hardpan).  

For treatment Dr. Hatzidakis recommends rest and low-impact preventative exercises with light weights to strengthen and elongate the extensors, tendons and flexors in your wrists, forearms and elbows. “You want strong and flexible wrists,” the doctor says.

In addition to OTC anti-inflammatories, treatments include wearing an offload strap around the meatiest part of the forearm to deflect force away from the epicondyle. “Lastly,” Dr. Hatzidakis says, “arthroscopic surgery can release the fibers and clean up the bone.” Rarely, an open repair with a one- to two-inch incision is required.

Dr. Armodisa Hatzidakis of Western Orthopaedics in Denver

The shoulder has a wider range of motion than the elbow, with a greater variety of soft tissue, joint cartilage and bone issues that can cause symptoms. “Shoulders are more tricky,” says Dr. Hatzidakis. “If you’re experiencing pain, see someone earlier rather than later. Sometimes it’s hard to just exercise your way out of it.”, Arthritis can also affect the shoulder, causing pain and dysfunction that limits golf performance. For those who have exhausted other approaches—such as exercise, physical therapy or arthroscopy, shoulder replacement can be a durable option. 

Patients with difficulty lifting their arm or swinging a golf club may also suffer with rotator cuff deficiency. This can result from a large tear in the rotator cuff (the four muscles that connect the humerus to the scapula and allow arm rotation) or other trauma.

Dr. Hatzidakis says he has also had success with reverse shoulder replacement, a process that reverses the anatomy and geometry of the shoulder, obviating the need of the rotator cuff to stabilize it for rotation. The prosthesis provides the stabilization, allowing the deltoid to help raise your arm or swing the club.

For more information, visit:

Denver Spine Surgeons: denverspinesurgeons.com

Orthopaedic Physicians of Colorado: orthophysicians.com

Western Orthopaedics: western-ortho.com

This article appears in the May 2016 issue of Colorado AvidGolfer.

See more from The 15th Club: Our Annual Health and Fitness Issue:

Cover Story: Going to the MAT with Greg Roskopf

Become Golf Strong: A Strength Program for Golf Fitness

To Repair or Replace? Orthopedic Answers for Golfers

Consider the Alternatives: Nonsurgical Options for Pain

Practice Makes Present: How Yoga Can Improve Your Golf Game

Pelvis Lives! How to Strengthen Your Pelvis for Your Golf Swing

The Skins Game: Protecting Your Skin on the Golf Course

Garden of Gods Club Builds Wellness Center

Colorado AvidGolfer is the state’s leading resource for golf and the lifestyle that surrounds it. It publishes eight issues annually and proudly delivers daily content via www.coloradoavidgolfer.com.