Tiger's Knee and the Cruel Twist to the Sport of Golf

Throughout his career Tiger Woods has been anything but ordinary. With his latest win he has now crossed the bridge from sports extraordinaire to orthopedics extraordinaire. Tiger’s latest feat is unique, and has brought a new awareness to injuries in the sport of golf. 

Anyone reading the sports section has seen just how extraordinary his career has become. Win after win, love him or hate him, Tiger is rarely off the leader board. After winning the U.S. Open in June with an injured knee, he has jumped to a new level of fame and respect. Even now, one month after his extraordinary win, his face is still hard to miss on ESPN. From a professional golf standpoint there is nothing ordinary about seeing such a big win under those circumstances and from an orthopedic standpoint it is far from ordinary!

For those who do not follow golf, Tiger Woods has a number of achievements on his resume which have made him extraordinary in the world of sports. Since his career began in 1996, Woods has won 65 official PGA Tour events out of the 222 he has participated in. That equates to over 29%. Woods now holds the lowest career scoring average of any player in PGA Tour history, while at the same time maintaining the highest level of career earnings.

While his career statistics are pretty impressive, it was his latest win at the 2008 U.S. Open which brought increased attention to the extraordinary abilities of this man and is now bringing greater orthopedic awareness to the sport as well. Throughout the event, Woods showed obvious signs of pain in his left leg, wincing during tee shots, and at times making great efforts to keep weight off of his left leg. Yet even with the obvious pain, Woods still won the event after an 18-hole playoff culminating in a sudden death playoff against Rocco Mediate.

Two days following Wood’s victory on his injured knee, Wood announced he would be missing the remainder of the 2008 PGA season due to a torn left anterior cruciate ligament (ACL) and a double stress fracture on the tibia of his left leg. Winning such a major event on the PGA by itself was a miraculous feat; however the circumstances under which Tiger Woods won were on a whole new level. Fellow golfer Kenny Perry was even quoted as saying, “He beat everybody on one leg.”

But aside from Tiger’s extraordinary abilities, what about from an orthopedic standpoint? Are Tiger’s injuries normal? If so, are these injuries common? Golf isn’t known as high-impact and few people expect to see injuries at the professional level, or even at the amateur level. But Tiger’s recent high profile win has begun to raise such questions.

To answer this it must first be established, what is normal? Just because golf doesn’t have the impact that sports such as football or rugby have does not mean injuries are not occurring. According to George D. Henning, M.D. of the Roanoke Orthopaedic Center, a touring professional golfer can expect to average two injuries a year. Furthermore, in the article entitled Keep Golf Injuries from Sending You to the Clubhouse, published by the American Academy of Orthopaedic Surgeons, the U.S. Product Safety Commission reported in 2007 alone more than 103,000 golf-related injuries treated in doctor’s offices, clinics, and emergency rooms. These injuries came at a cost of approximately $2.4 billion in total expenses, including medical fees, lost time at work, pain and suffering, and legal fees.   

Such numbers could lead one to believe brawls are taking place in sand traps across the nation and people have all but stopped yelling FORE!  Fortunately that isn’t quite the case. While golf-related injuries may be more common than expected, the vast majority of injuries in the sport result from damage sustained over long periods of time. This damage is typically due to the stress of the unnatural motion of the swing upon various parts of the body. Some of the more common diagnoses are back pain, golfer’s elbow, shoulder pain, carpal tunnel syndrome, and knee pain. 

Does this mean Tiger’s knee problems are common among all golfers? The answer to this is both yes and no.  We cannot forget that as good as Tiger may be, he is still human. Because of this, in one key respect he is like all golfers, the swing of the golf club forces an intense twisting action upon the knee. This twisting action can exacerbate numerous underlying problems within the knee. The most common of these are arthritis, chondromalacia, torn menisci, and tendonitis.

Looking back through Tiger’s history, he has seen past medical issues specifically with his left knee. 

• In 1994 Woods had a benign tumor removed from his left knee. 
• In 2002 he had a benign cyst removed from his left knee and fluid drained around the ligaments. 
• In 2007, while running at his home Tiger ruptured his anterior cruciate ligament. 
• Early 2008, he underwent arthroscopic knee surgery to clean out cartilage from his left knee.
• June, 2008, he announced torn left anterior cruciate ligament and a double stress fracture on the tibia of his left leg

The trend of Tiger’s left knee seems to be a clear demonstration that underlying knee problems coupled with continued stress upon the joint during golf is continuing to bring these problems to the surface. The knee pain demonstrated during the U.S. Open seems a direct result of this. While the injuries sustained to Tiger’s knee are not necessarily among the more common diagnoses of the knee in relation to golf injuries, the problem itself is quite similar to that of the ordinary golfer.

But here again Woods is far from ordinary. During his celebrated win at the U.S. Open, Tiger did not have just one injury to his knee. Instead his anterior cruciate ligament was torn and he suffered from multiple stress fractures to his tibia, with both injuries occurring on the same leg. Is this really common in golfers? Taking this a step further, let’s take golf out of the picture for a moment and ask, is this common for anyone? 

Table 1: Patients With Injury to ACL and Stress Fracture(s) of Tibia 2004-2006

This answer is of course no. Taken from the PearlDiver database of over 22 million distinct patients, from 2004 through 2006 we can see how uncommon Tiger’s situation is. Looking at Table 1 above in the same age group as Tiger, 30 to 39, of the nearly 34,000 patients diagnosed with an ACL injury and over 1,000 patients with a stress fracture of the tibia, only 6 patients suffered both injuries at the same time. In total, of the 22 million patients within the database, while over 140,000 patients suffered and ACL injury and over 8,000 suffered a stress fracture of the tibia, still only 23 patients over a 3-year period had the misfortune of suffering both injuries at the same time. Using this information, it can be concluded that the likelihood of both injuries simultaneously is extremely low.

Disregarding this information, what are the odds that an athlete, at even the highest of skill levels would be able to win the U.S. Open? Furthermore, what are the odds that this athlete could win the U.S. Open under the misfortune of suffering from both a torn ACL and multiple stress fractures of the tibia? But this isn’t just an ordinary person.

From an orthopedic standpoint, Tiger Woods has clearly grabbed our attention. However, just one point of orthopedic interest simply wouldn’t be enough for a person of Tiger’s caliber. Setting himself even further apart, instead of the traditional single-bundle method to reconstruct his torn ACL, according to Bloomberg News Woods has reportedly instead opted for the newest technique known as the double-bundle method. What’s the difference? The ACL is composed of two ligament bundles, the anteromedial and the posterolateral. In the commonly used single-bundle method of reconstructive surgery both of these bundles are replaced with just one ligament bundle using either a hamstring tendon or a patellar tendon. The double-bundle method seeks to improve this reconstruction process by replacing both bundles. The primary goal of changing the reconstruction technique is better restoration of the patient’s range of motion within the knee and improved knee stability from the status quo single-bundle method. This is still a fairly new procedure here in the U.S. It’s technically difficult, and still has its share of skeptics. As to what the expected outcome is, it can only be assumed that Tiger is planning on making a full recovery. Yet the point is that Tiger has moved one step further down the road toward extraordinary from an orthopedic point of view. The debate over the double-bundle method is truly interesting, but can be saved for another article. 

Throughout Tiger’s miraculous win and the time since, he has accomplished what few other athletes have. He has increased fans interest in the sport of golf, and in the process, increased interest in an entirely different genre, orthopedics. As for the outcome of Tiger’s knee procedure, it is expected that we will be waiting at the very least until the beginning of the 2009 PGA Tour to see how effective it has been.