however , reports of golf swing - related fractures include stress fracture of the ribs , ulnar diaphysis , vertebral body , sternum , and hook of hamate2,6,9,15,17 ) . to our knowledge ,
only one case of multiple spinous process fractures of the upper thoracic spine in a beginning golfer has been reported14 ) .
we report a case of multiple cervical spinous process fractures in a novice golf player and discuss its pathomechanism .
a 45-year - old female presented with intractable posterior neck pain that had lasted for 11 days .
the severity of the pain had prevented sleep and rotation of the neck for 7 days .
the patient had experienced a sharp and sudden pain on the posterior neck during a golf swing .
the pain began when the club contacted the ground instead of the golf ball . under the impression of acute sprain ,
there was no notable history of medical illness , such as diabetes , hypertension and osteoporosis . on physical examination ,
the patient complained of severe tenderness over the lower mid - cervical area and , in particular , limited range of motion during flexion and extension .
however , swelling and ecchymosis were not evident at the tender point . the findings of neurological symptoms and signs were normal .
dynamic cervical radiographic findings were fractures in the spinous processes of c6 and c7 vertebrae without instability ( fig .
the patient underwent cervical magnetic resonance imaging ( mri ) with a suspicion of other occult trauma around c6 and c7 .
2c ) revealed high signal areas in interspinous and supraspinous ligaments between the c6 and c7 vertebra suggestive of an acute injury to cervical spine . under the diagnosis of stable c6 and c7 spinous process fractures ,
the patient was prescribed with pain medications and wearing a cervical collar was recommended for 6 weeks . after cervical bracing and medication , pain gradually improved .
it requires a coordinated sequence of whole body muscle activity to efficiently transfer the power generated by the swing19 ) . during the each phase of a golf swing
there have been a number of reports of golf related injuries ( table 1)2,6,7,9,14,15,17,18 ) .
but , only one report has described multiple spinous process fractures of the upper thoracic spine caused by golf swing itself14 ) .
but , the follow - up mri revealed the additional fracture in the spinous process of the second thoracic vertebra .
the pathomechanism of this type injury remained ill - defined and was presumed to be similar to clay - shoveler 's fracture10 ) .
avulsion of spinous process or clay - shoveler 's fracture was first described in australia10 ) .
more recently , it has also been described during nintendo wii activity4 ) , volleyball13 ) , car accident1 ) , power lifting12 ) , and golf14 ) .
it occurs when the head and upper cervical segments are forced into flexion against the opposing action of the interspinous and supraspinous ligaments11 ) .
the injury takes its ' name from the fact that , during the throwing phase of shoveling , clay may stick to the shovel and jerk the trapezius and other muscles attached to lower cervical or upper thoracic spinous processes10 ) .
it can also occur with a whiplash injury , injuries that jerk the arms upwards , neck hyperflexion , or a direct blow to the spinous processes10 ) . in our case
the trapezius muscle originates from the medial one - third of the superior nuchal line and the external occipital protuberance of the occipital bone , from the spines of the seventh cervical and all thoracic verbetrae , and from the intervening supraspinal ligament20 ) .
it is relatively flat and thin , but its thickness increases in the lower cervical and upper thoracic region20 ) . where its increased thickness is matched by a distinct diamond - shaped accumulation of tendinous fibers of origin20)(fig .
the spinous process is relatively longer in the lower cervical than the upper cervical area .
its fibers converge toward the bones of the shoulder20 ) . during the back swing , the right upper and middle trapezius muscle contracts19)(fig .
3b , c ) . during the forward swing , the left middle trapezius muscle contracts19)(fig .
3d ) . so we can postulate that muscular contraction moves from right side to left side , like a bow .
because of the pectoralis muscle , the force may be amplified during the acceleration phase ( fig .
when a right - handed golfer swings so the club contacts the ground prior to the ball , the energy accumulated during the back swing can not be transmitted to the ball ( fig .
3f ) . there is a sudden change of muscle contraction from the right upper and middle trapezius to its attachment point ( the spinous process ) . if enough force is transmitted through the trapezius tendon , spinous process fracture is possible .
when the force is not strong enough to make fracture , if applied repeatedly , overuse or stress - type fracture may occur .
atypically , this fracture may extend to the lamina , thereby involving the spinal canal with the potential of spinal cord injury11 ) .
if a patient complains of long lasting neck pain , the attending clinician should have further study ( cervical spine radiographs , computed tomography scan or cervical mri ) to rule out other occult fractures or injuries16 ) .
midline tenderness may be the clue for the presence of fracture . if the lower cervical spine and/or cervico - thoracic junction are not well visualized on cervical spine lateral radiographs , a swimmer 's view5 ) or ct scan15 ) should be obtained .
so , warming up and stretching exercise before golf will reduce the risk of golf related injury8 ) .
lower cervical spinous process fractures , even minor stable fractures , can be associated with the golf swing .
if a patient complains of long lasting neck pain and has a history of golf play , lower cervical spinous fracture should be suspected and ruled out .
 avulsion of spinous process , also called clay - shoveler 's fracture , is most prevalent among those engaged in hard physical labor . to the best of the author 's knowledge , 
 only one case of multiple spinous process fractures of the upper thoracic spine in a novice golfer has been reported . a 45-year - old female presented with intractable posterior neck pain . 
 the patient experienced a sharp , sudden pain on the neck while swinging a golf club , immediately after the club head struck the ground . 
 dynamic cervical radiographic findings were c6 and c7 spinous process fractures . 
 magnetic resonance imaging revealed c6 and c7 spinous process fractures without spinal cord pathology . 
 the patient was treated with pain medications and cervical bracing . 
 the patient 's pain gradually improved . 
 the injury mechanism was speculated to be similar to clay - shoveler 's fracture . 
 lower cervical spinous process fractures can be associated with a golf swing . 
 if the patient complains of long lasting neck pain and has a history of golf activity , further study should be conducted to rule out lower cervical spinous fracture . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION