By Marc Darrow, MD, JD

On my Living Pain-Free radio program, I spoke with Gilbert, an accomplished golfer whom I have treated over many years. When we first met, back pain limited him to playing perhaps once or twice a week. He later reported that, after regenerative treatment and an appropriate period of rest, he returned to golf with less pain, greater flexibility, and the ability to play several days a week.

Gilbert’s experience offers an important starting point, but it is one patient’s story—not proof that platelet-rich plasma or bone marrow concentrate will produce the same result for every golfer. The larger lesson is diagnostic: “lower-back pain” is a symptom, not a precise anatomical diagnosis.

A golfer may have pain arising from a disc, facet joint, sacroiliac joint, ligament, tendon, muscle attachment, nerve, hip, or a combination of structures. An MRI may reveal several abnormalities without identifying which one is responsible. Before considering PRP, bone marrow concentrate, surgery, or any other procedure, we must first ask: What structure is generating the familiar pain?

Why the golf swing places unusual demands on the lower back

The golf swing is a rapid, coordinated motion involving the feet, legs, hips, pelvis, trunk, shoulders, arms, and club. Power should move through this kinetic chain. When hip mobility, thoracic rotation, strength, timing, or balance is limited, the lumbar spine may be asked to create or absorb more motion than it should.

During a forceful swing, the lower back experiences combinations of:

  • axial rotation, or twisting;
  • compression;
  • shear;
  • side bending;
  • flexion and extension; and
  • rapid muscular acceleration and braking.

These forces are repeated during practice swings, full shots, and long sessions at the driving range. A golfer who hits 100 balls has not performed one isolated athletic movement; the golfer has repeated a high-speed rotational task 100 times.

A review of golf-related low-back pain identified swing mechanics, trunk-muscle control, hip mobility, repetitive loading, and practice volume among the factors that may contribute to symptoms. (1) Researchers have also examined the “crunch factor”—the combination of rapid trunk rotation and lateral bending—as a potential contributor to lumbar loading, although the relationship between this single measurement and actual injury is not simple. (2)

The practical message is not that golfers should stop rotating. Rotation is fundamental to the sport. The objective is to distribute motion efficiently through the hips and thoracic spine while the trunk muscles control, rather than repeatedly overload, the lumbar region.

Golf-related lower-back pain can come from several structures

It is tempting to look at an MRI report, find “degenerative disc disease,” and assume the disc must be the source of pain. Sometimes it is. Frequently, the situation is more complicated.

Intervertebral discs

The discs sit between the vertebral bodies and help distribute load. A disc can lose water content, become thinner, develop fissures in its outer ring, bulge, or herniate. Disc-related pain is often described as deep central lower-back pain and may worsen with sitting, bending, lifting, or repeated flexion. A herniated disc that irritates a nerve can produce leg pain, numbness, tingling, or weakness.

However, a degenerative disc on MRI is not automatically a painful disc.

Facet joints

The paired facet joints at the back of the spine guide motion and share load. They may become painful through arthritis, capsular irritation, repetitive extension, or combined extension and rotation. A golfer with facet-mediated pain may feel pain to one side of the lower back, sometimes extending into the buttock or upper thigh. Symptoms may worsen with standing, arching, or rotating, but these patterns are not diagnostic by themselves.

Sacroiliac joints

The sacroiliac joints connect the sacrum to the pelvis and transfer force between the trunk and legs. Pain may be felt near one side of the beltline or buttock and can be confused with lumbar or hip pain. Because the golf swing transfers force across the pelvis, limited hip motion or poor control can increase stress in this region.

Muscles and fascia

The paraspinal, multifidus, quadratus lumborum, abdominal, gluteal, and hip muscles help produce and control the swing. A strain can occur suddenly, but pain can also develop from fatigue, guarding, poor conditioning, or an overload that exceeds the tissue’s capacity.

Ligaments, tendons, and attachment sites

Ligaments help control motion between bones. Tendons connect muscles to bone. These collagen-rich structures and their attachment sites can be injured by sudden force or repetitive loading.

An enthesis is the point where a tendon or ligament attaches to bone. Enthesopathy refers to injury, degeneration, or irritation at that attachment. Around the lumbopelvic region, tenderness can develop at muscle, tendon, fascial, or ligament attachments along the pelvis, sacrum, and lumbar vertebrae.

In my clinical experience, some golfers have highly localized attachment-site pain that is overshadowed by impressive—but potentially incidental—MRI findings. Published reviews have also proposed that damaged spinal ligaments and lumbar instability may contribute to chronic low-back pain in a subset of patients, although stronger clinical trials are needed to confirm diagnostic criteria and treatment effects. (3)

Why an abnormal lumbar MRI may not reveal the pain generator

MRI is extremely valuable when used for the right reason. It can demonstrate disc herniation, nerve compression, stenosis, fracture, infection, tumor, and other important abnormalities. The problem arises when every age-related finding is assumed to explain the pain.

A systematic review of 3,110 people without back pain found degenerative findings to be common and increasingly prevalent with age. Disc degeneration was present in an estimated 37% of asymptomatic 20-year-olds and 96% of asymptomatic 80-year-olds. Disc bulges were estimated in 30% of asymptomatic people at age 20 and 84% at age 80. (4)

This does not mean MRI findings are meaningless. It means they must be matched to the history, physical examination, neurologic findings, and pattern of symptoms.

I want to know:

  • Where is the pain felt?
  • Is it central or clearly one-sided?
  • Does it travel below the knee?
  • Are numbness, tingling, or weakness present?
  • Does sitting, bending, extension, walking, or rotation reproduce it?
  • Is there a precise area of tenderness?
  • Is hip rotation restricted?
  • What happens during the swing and after the round?
  • Does the patient hurt after a few shots, late in the round, or the following day?

The answer may point toward the disc, facet, sacroiliac joint, a soft-tissue attachment, the hip, or more than one structure. Sometimes a targeted diagnostic injection is appropriate, but no test should be interpreted in isolation.

Red flags require conventional medical evaluation

Not every golfer with back pain is a candidate for a regenerative procedure. Urgent assessment is needed for new bowel or bladder dysfunction, saddle numbness, progressive leg weakness, severe pain after substantial trauma, fever, unexplained weight loss, a history of cancer, suspected infection, or symptoms suggesting fracture or cauda equina syndrome.

Regenerative injections are also not treatments for major nerve compression, severe progressive neurologic loss, unstable fracture, tumor, infection, or every case of advanced spinal stenosis.

When PRP may be considered

Platelet-rich plasma is prepared from a patient’s own blood. It contains concentrated platelets and signaling proteins involved in inflammation and tissue repair. Depending on the working diagnosis, a clinician may discuss PRP for selected ligament, tendon, muscle-attachment, facet-capsule, or sacroiliac-region problems that have not improved with appropriate rehabilitation.

Evidence for many of these paraspinal applications remains limited. Studies often use different PRP formulations, diagnostic criteria, injection targets, comparison treatments, and outcome measures. A proposed biological mechanism does not prove clinical effectiveness.

PRP has also been injected directly into lumbar discs for carefully selected patients with suspected discogenic pain. A 2022 systematic review and meta-analysis of 13 studies involving 319 patients found improvement in pain measures but not consistent improvement in disability or MRI structure. The authors emphasized heterogeneity and a shortage of high-quality trials. (5)

A 2022 randomized trial of intradiscal PRP in patients without Modic changes did not establish a broadly applicable answer, and intradiscal studies remain difficult to compare because patient selection and product preparation vary. (6) A 2026 prospective cohort reported improved pain and disability at six months among participants who completed follow-up, but it had no randomized control group and did not show meaningful whole-disc structural recovery on quantitative MRI. (7)

Therefore, intradiscal PRP should be described as an investigational option—not proven disc regeneration.

What bone marrow concentrate is

Bone marrow concentrate is collected from a patient’s bone marrow, usually from the pelvic bone, and processed to concentrate nucleated cells, platelets, and signaling molecules. It includes a small population of progenitor cells but is not a purified or culture-expanded stem-cell product.

Calling every bone marrow concentrate procedure “stem cell therapy” can create unrealistic expectations. The biological mixture may influence inflammation or tissue signaling, but an injection cannot be assumed to rebuild a worn disc, restore normal spinal anatomy, or correct severe mechanical compression.

Bone marrow concentrate for discogenic back pain: what the evidence shows

Early small case series created optimism. In one study, 26 patients with discogenic pain received intradiscal bone marrow concentrate and reported improvements over three years. Without a sham or placebo group, however, it was impossible to determine how much of the improvement resulted from the injectate, patient selection, natural history, rehabilitation, expectation, or other factors. (8)

A 2022 systematic review of intradiscal biologic treatments rated the overall evidence as very low quality. It found too few rigorous comparative trials to define effectiveness with confidence. (9)

Most importantly, a 2025 double-blind, randomized, sham-controlled trial evaluated a single intradiscal bone marrow concentrate injection for chronic discogenic low-back pain. Bone marrow concentrate did not demonstrate superiority over the sham procedure at the evaluated time points. Both groups improved, underscoring the importance of placebo effects, natural variation, and rigorous controls when evaluating an invasive pain procedure. (10)

This trial materially changes how the evidence should be presented. Bone marrow concentrate for discogenic low-back pain remains investigational. Patients should not be promised that the injection will regenerate a disc or allow them to avoid surgery.

An injection into the disc is not the same as treating tissues around the spine

The term “stem cell therapy for back pain” can refer to very different procedures:

  • an intradiscal injection;
  • treatment around a facet joint or its capsule;
  • treatment of a sacroiliac region;
  • injection at a ligament or tendon attachment; or
  • treatment of another musculoskeletal structure mistaken for spinal pain.

Evidence for one target cannot automatically be transferred to another. A study of an intradiscal injection does not prove that a paraspinal ligament injection works, and a study of knee osteoarthritis does not establish effectiveness in the lumbar spine.

This is why diagnosis and anatomical precision matter more than the general label “regenerative medicine.”

A staged return to golf

Return to play should be based on symptoms, function, diagnosis, and the procedure performed. There is no universal timetable. A reasonable progression may include:

Stage 1: Settle the irritated tissue

Avoid full swings and heavy rotational loading while maintaining comfortable walking and prescribed mobility. Prolonged bed rest is generally not the goal.

Stage 2: Restore capacity

Progress hip and thoracic mobility, trunk endurance, gluteal strength, balance, and controlled rotation. The golfer should tolerate daily activities and rehabilitation without a significant delayed flare.

Stage 3: Rehearse the swing without full load

Begin putting and chipping, then half-swings with shorter clubs. Emphasize rhythm, balanced finish, and motion through the hips and thoracic spine.

Stage 4: Build volume before intensity

Increase the number of swings gradually before trying to maximize club-head speed. Start with a small bucket rather than a full range session. Recovery the next day matters as much as comfort during practice.

Stage 5: Return to the course

Begin with fewer holes, avoid repeated high-effort shots, and consider walking-versus-cart demands individually. Increase playing frequency only when the back tolerates the current level.

Following an injection, the treating physician’s protocol takes precedence because the target, needle pathway, and biological product affect restrictions. Pain relief should not be interpreted as immediate restoration of tissue strength.

Who may be considered—and who may not be

A possible candidate for an orthobiologic procedure generally has a specific, clinically supported pain generator; persistent symptoms despite appropriate conservative care; realistic expectations; and the ability to participate in rehabilitation.

A poor candidate may have an uncertain diagnosis, primarily neurologic compression requiring surgical evaluation, advanced instability or deformity that an injection cannot correct, active infection, uncontrolled medical illness, or an expectation that one injection will restore a normal MRI and permanently eliminate pain.

The goal is not merely to treat the MRI

Gilbert’s experience was meaningful to him: he reported less pain, better flexibility, and a return to frequent golf. It illustrates what patients hope to regain—the activity they love. It does not establish that every golfer with disc degeneration needs a “stem cell” injection.

For the golfer with chronic lower-back pain, the best first question is not, “Can stem cells fix my back?” It is:

What structure hurts, why is it being overloaded, and what is the least invasive evidence-based plan for restoring function?

Sometimes the answer is rehabilitation and swing modification. Sometimes a carefully targeted PRP procedure may be discussed. In selected investigational circumstances, an intradiscal orthobiologic procedure may be considered after a frank discussion of the conflicting evidence. Sometimes surgery is necessary.

At the Stem Cell Institute and Joint Rehab, the objective is to make the diagnosis before selecting the treatment—and to help the patient return to golf safely rather than simply treating an image.

References

  1. Lindsay DM, Vandervoort AA. Golf-Related Low Back Pain: A Review of Causative Factors and Prevention Strategies. Asian J Sports Med. 2014;5(4). doi:10.5812/asjsm.24289.
  2. Cole MH, Grimshaw PN. The Crunch Factor’s Role in Golf-Related Low Back Pain. Spine J. 2014;14(5):799-807. doi:10.1016/j.spinee.2013.09.019.
  3. Hauser RA, Matias D, Woznica D, Rawlings B, Woldin BA. Lumbar Instability as an Etiology of Low Back Pain and Its Treatment by Prolotherapy: A Review. J Back Musculoskelet Rehabil. 2022;35(4):701-712. doi:10.3233/BMR-210097.
  4. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.
  5. Muthu S, Jeyaraman M, Chellamuthu G, Jeyaraman N, Jain R, Khanna M. Does the Intradiscal Injection of Platelet Rich Plasma Have Any Beneficial Role in the Management of Lumbar Disc Disease?. Global Spine J. 2022;12(3):503-514. doi:10.1177/2192568221998367.
  6. Schepers MO, Groot D, Kleinjan EM, et al. Effectiveness of Intradiscal Platelet Rich Plasma for Discogenic Low Back Pain Without Modic Changes: A Randomized Controlled Trial. Interv Pain Med. 2022;1(1):100020. doi:10.1016/j.inpm.2022.100011.
  7. Pan X, Peng G, Yao Q, et al. Intradiscal Platelet-Rich Plasma for Discogenic Low Back Pain: A Prospective Cohort Study of Early Clinical Outcomes and Quantitative MRI Findings. Sci Rep. 2026;16:14161. doi:10.1038/s41598-026-42909-x.
  8. Pettine KA, Suzuki RK, Sand TT, Murphy MB. Autologous Bone Marrow Concentrate Intradiscal Injection for the Treatment of Degenerative Disc Disease With Three-Year Follow-up. Int Orthop. 2017;41(10):2097-2103.
  9. Schneider BJ, Hunt C, Conger A, et al. The Effectiveness of Intradiscal Biologic Treatments for Discogenic Low Back Pain: A Systematic Review. Spine J. 2022;22(2):226-237. doi:10.1016/j.spinee.2021.07.015.
  10. Levi D, Horn S, Tyszko S, Levin J. Bone Marrow Concentrate Intradiscal Injection for Chronic Discogenic Low Back Pain: A Double-Blind Randomized Sham-Controlled Trial. Interv Pain Med. 2025;4(3):100611. doi:10.1016/j.inpm.2025.100611.

Medical disclaimer

This article is for educational purposes and is not medical advice. PRP and bone marrow concentrate procedures are not FDA-approved treatments for a specific spinal disease. Intradiscal injections carry risks, including infection and disc injury, and should be considered only after an individualized medical evaluation. Seek urgent care for new bowel or bladder dysfunction, saddle numbness, progressive weakness, fever with back pain, or severe symptoms after trauma.