The Importance of Pelvic-Trunk Dissociation

The definition of dissociation is “the disconnection or separation of something from something else.”  In golf, this is especially important in regards to pelvis and thorax (trunk) separation.  The reasons are many and include everything from proper sequencing/ timing of the swing to production of club head speed and power.  This is clearly observed in what the Titleist Performance Institute coined “The Kinematic Sequence.”  A full review can be found —> HERE, but the basics are as follows:

Notice how the red line increase
The above graphs compare the swing sequence of a professional (left graph) and two amateurs (middle and right graph). Notice that in the left graph the red line which represents the pelvis/lower body rapidly slopes upward starting at the top position and is followed closely in sequence by the thorax, arm, and club.  Also, notice that because of this sequence the club rotation speed is much greater than the two amateurs (indicated by the yellow line being much higher). However, in the amateurs, the lines are not in sequence and it is obvious that the pelvis line is flatter which represents less acceleration.  See below for more details from TPI.

1) There is an identical sequence of speed or energy generation for all great ball strikers. That sequence is: lower body first (red line on the graph above), trunk or torso second (green line), arms third (blue line), and the club last (yellow line). This sequence occurs during the downswing.

2) Each segment of the body builds on the previous segment, increasing speed up the chain. (Red is less than green, which is less than blue, which is less than yellow).

3) Each segment of the chain slows down once the next segment begins to accelerate. This is due to the distal segment pushing off the proximal segment.  Imagine a child jumping off their dad’s shoulders in a swimming pool.  As the child jumps, the force rapidly slows down the dad’s energy.  This causes a sequential deceleration or stabilization of the segments.

4) Unorthodox styles may have no effect on your ability to generate a good kinematic sequence. In other words, Jim Furyk and Davis Love can have the same kinematic sequence.

As with any graph, the kinematic sequence graph can be confusing.  But, the take home message is that all great ball strikers initiate the downswing with the lower body and pelvis first allowing the other body parts to accelerate and generate speed behind it in the proper sequence.  If this does not happen, it can be due to a technique flaw which would require the guidance of a golf professional to improve swing mechanics.  But, it also can be a physical limitation whereas the golfer is unable to dissociate the pelvis from the trunk because of flexibility or motor control deficits.  If this is the case, it makes it very difficult to create a large turn in the back swing and/or begin the downswing with the lower body.  Thus, the trunk comes with the pelvis causing improper sequencing and an unpredictable shot pattern (usually a block, slice, or duck hook).  This is especially apparent in the over the top and early extension swing characteristics.  A review and video of “over the top” can be found —> HERE and “early extension” —> HERE.

The only way to truly know if a physical limitation is contributing to the inability to dissociate during the golf swing is to assess the athlete by administering a physical screen.  There are several tests that we use to qualitatively and quantitatively assess dissociation and they are as follows.

  1. The Pelvic Rotation Test which qualitatively tests the ability to dissociate the pelvic on a stable trunk (think downswing).
    1. View the test —> HERE.
  2. The Torso Rotation Test which qualitatively test the ability to dissociate the torso on a stable pelvis (think backswing).
    1. View the test —> HERE.
  3. The Seated Trunk Rotation Test which quantitatively tests if the golfer has enough mobility in the trunk (important in the backswing and downswing).
    1. View the test —> HERE.
  4. The Lower Quarter Rotation Test which quantitatively tests if the golfer has enough hip mobility (important in both backswing and downswing).
    1. View the test —> HERE.

Let’s identify dissociation in a real swing….

tiger-woods-golf-swing

To help illustrate dissociation, let’s pretend that the golfer above is standing in the middle of a clock and his club in image #1 (address) is pointed towards 6 o’clock.  Likewise, in this image his belt buckle (pelvis) and buttons of his shirt (trunk) are pointed towards 6 o’clock.  Here there is no dissociation or separation.  However, at the top of his backswing (image #2) his belt buckle is pointed towards 7 or 8 o’clock and his trunk is pointed at least to 9 o’clock.  Now we are beginning to see some separation; in other words the pelvis and trunk aren’t pointing in the same direction.  Furthermore,  during the downswing (image #3) there is even more separation in which his belt buckle is pointing towards 5 o’clock, and his trunk is still back at around 8 o’clock.  This increase in separation that begins in the down swing is called X-Factor Stretch and will be discussed later.  Basically, this helps take the potential energy stored in the backswing and transfers it to kinetic energy and increase club head speed.  If you want to read more about it please click —> HERE.

In summary, the ability to create separation and dissociate the hips from the torso is paramount in golf especially with the modern swing.  In order for this to occur the golfer must have adequate neck, spine, shoulder, and hip mobility as well as proper coordination and motor control for the kinematic sequence to occur.  Poor skill and swing mechanics can negate this from happening, but more often than not it is a physical limitation (flexibility or strength deficit) which can be assessed and corrected with specific exercises.  If you are interested in learning if you have any physical limitation that is hindering your golf performance, find a Certified TPI Professional near you by clicking —> HERE.  

 

 

 

 

 

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Failed Seated Trunk Rotation Test? Now What?

Before we get started, let’s review the Seated Trunk Rotation Test (STRT).  To view the test on TPI’s website click —> HERE.

1) Assume a seated position with knees and feet together 2) Place golf club on chest 3) While keeping the club parallel to the ground, rotate as far as possible 4) Repeated with club on back
1) Assume a seated position with knees and feet together 2) Place golf club on chest 3) While keeping the club parallel to the ground, rotate (both directions) as far as possible 4) Repeat all with club on back

As per TPI, the test is designed to “identify how much rotational mobility is present in the thoraco-lumbar spine.” This is very important to understand because most would assume a failed test is caused by the thoracic spine alone.  Though this is most often the case, it is incorrect to assume because the lumbar spine does contribute to approximately 10-15 degrees of axial rotation which is most limited by the sagittal orientation of the facet joints. Each joint/segment only allow 2-3 degrees of rotation [1].  Contributing the most to rotation of the trunk is the t-spine which should rotate 45-50 degrees [1].  Therefore, we need to have the ability to dissociate thoracic mobility deficits from lumbar mobility deficits to identify the specific area that is limiting motion.  More on this later.

Architecturally incompetent for rotation compared to the T-spine and Hips!
Architecturally incompetent for rotation compared to the T-spine and Hips!

It is also important to understand how a failed Seated Trunk Rotation Test is interpreted. The STRT is part of the TPI Screen which is used to screen golfers.  This screen is a series of tests that can be used by any member of The Team, and as we know from the Functional Movement Systems principles, only evaluates risk.  It is not a medical evaluation or performance test.  In other words, do not get caught up on trying to diagnose the cause of the dysfunction from this quick screen, or to determine the skill of the athlete.  Just understand the findings, and put that athlete in the hands of someone who can further assess the impairment.

This leads us to the first member of The Team – the golf instructor.  For more information on the team approach click —> HERE.  Just as it is not appropriate for a medical or fitness professional to give swing advice, it is not appropriate for the golf professional to give medical or fitness advice (unless they are licensed or certified).  With that said, if the golf instructor determines that the athlete has failed this test they should consult the medical professional.  It is my opinion that the medical professional should be consulted before the fitness professional because Low Back Pain is the #1 injury in golf and thoracic spine pain is the top injury related to lost practice time [2].  So, we want to make sure that a mobility deficit is all that needs to be addressed.  Together, the medical and golf pro can determine whether this deficit is causing a swing fault, and if movement optimization would improve their swing.

Further Evaluation of the STRT (a.k.a. The Breakout)

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…”a clinical assessment system designed to identify musculoskeletal dysfunction by evaluation of fundamental movements for limitations or symptom provocation.” In other words, use it to find the cause of the problem.

Once the golfer is referred to a medical professional, he or she will systematically evaluate (breakout) the movement pattern by using a standardized evaluation process.  In my opinion, the most sophisticated is the Selective Functional Movement Assessment. However, other tests should be used especially if there is pain associated with this movement.  It should be understood that the STRT is part of the breakout of one of the top-tier tests in the SFMA.  However, it is not the purpose of this post to elaborate on this, but only to educate the reader on how to determine if the mobility deficit is thoracic or lumbar (or both) in nature from a failed STRT.  The medical professional will evaluate all movement patters of the athlete, but in terms of spinal rotation they will use an algorithm that uses to primary tests: 1) Lumbar Locked T-Spine Rotation Extension and 2) Prone on Elbow Unilateral Rotation/Extension.

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1A) Lumbar Locked T-Spine Ext/Rot ER….Functional = 50 degrees.

 

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1B) Lumbar Locked T-Spine Ext/Rot IR…..Functional = 50 degrees.

 

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2) Prone on Elbows Ext/Rot…..Functional = 30 degrees.

Starting with the Lumbar Locked position which isolates the thoracic spine, the athlete will assume a hands on head (ER) position shown in the picture 1A above.  A video demonstration can be seen by clicking —> HERE.  If this is found to be functional the t-spine is clear and the prone on elbows test will be conducted to assess the lumbar spine.  However, if the lumbar locked ER test is dysfunctional (<50 degrees) the lumbar locked IR position will be performed as shown in 1B.  This helps to isolate the t-spine and rule out the shoulder girdle’s relationship a rotation limitation.  If both are found to be dysfunctional, then the t-spine is in fact the culprit.  If 1A (ER) is dysfunctional but 1B (IR) is functional the shoulder girdle should be evaluated further (broken out), as well as the lumbar spine.

To further evaluate the thoracic spine, all planes of motion should be performed and overpressure can be used to increase the sensitivity of the test.  In other words, have the patient flex, extend, and rotate in isolated planes and add overpressure to understand full active and passive motion in addition to the above tests.  If the clinician determines that further isolation is necessary, local joint play testing can be used to determine segmental mobility.

Once a conclusion is drawn to the area of the spine that is limiting spinal rotation, the golf pro and medical professional should consult and devise a plan that is individualized.  Once this plan is created, the golfer should be educated on the findings of the test and evaluation, its implications to the golf swing, and how interventions relating to improving spinal mobility will improve their swing/ durability/ performance/ etc.

 

References

1. Pearcy MJ, Tibrewal SB. Axial rotation and lateral bending in the normal lumbar spine measured by three-dimensional radiography. Spine. 1984;9(6):582–587.

2. Cabri J, Sousa JP, Kots M, Barreiros J.  Golf-related injuries: A systematic review.  European Journal of Sport Science. 2009; 9(6):353-366.

The Team Approach to Golf Training

The team approach is something that is at the forefront of healthcare in the United States.  Even in physical therapy school we were encouraged to co-treat with other members of the healthcare team such as nurses, physicians, pharmacists, social workers, etc.  This, in theory, should maximize patient care by employing what I refer to as “division of labor”.  Every member of the healthcare team has a specialty, and should the patient need that specific division of service, the outcomes will be improved. Everyone is happy. Everyone wins.

This same model is the hallmark of the Titleist Performance Institute and is a new wave, cutting edge approach to golf training. No matter how high or low the handicap, I believe that this approach should be part of every golfer’s training regimen.

Before I discuss the modern team approach and what it means for the potential improvement of every golfer, let’s discuss “the old approach” of the 1990’s.  As described by TPI, the PGA of America would teach their instructors that the best way to fully serve their golfer was to have them consult with three professionals:

  1. The Golf Coach/ Instructor
  2. The Sports Psychologist/ Psychiatrist
  3. The Golf Club Manufacturer

Then, in 1996 something happened that would change the game as we know it.  Perhaps a more appropriate phrase is that someone happened.

Love him or hate him, he changed the game.
Love him or hate him, he changed the game.

Tiger’s game was different than anyone had seen before.  Power, strength, flexibility, and a chip on his shoulder.  These attributes began to affect the way competitors were preparing for the game,  and with that, the “team” became larger.  The newest addition was what was termed “physical conditioning” and included improving aspects of the body that influence performance.

The Modern Approach

The Modern Approach to the team has all of the members that were included in the old approach including golf coach, club manufacturer, and sports psych.  Now, several new members are on every tour pro’s team including business manager, strength and conditioning coach, and the medical professional (usually a physio).  This post will detail three of members of the modern team and how the communication between these three professionals can improve the performance of the golfer.  It is also important for each member to understand the “division of labor” and know when to consult another team member.  The three team members that will be detailed include:

  1. The Golf Coach/ Swing Instructor
  2. The Medical Professional (Physiotherapist/ Physical Therapist)
  3. The Fitness Professional (Strength and Conditioning Coach)

The Team

  1. The Golf Coach/ Swing Instructor
    1. It goes without saying how important the swing instructor/ golf coach is to the golfer.  Understanding the swing and implementing drills and exercises with the use of modern technology to optimize the player’s grip, stance, backswing, downswing, spin, launch angle, etc. is paramount.  However, I would like to propose something that many golf instructors may not consider. I believe that optimizing movement (improving flexibility, strength, balance, and other physical characteristics) so that the golfer is capable of performing the tasks that are instructed by the coach and to have durability to endure hours of practice will allow the player to rapidly improve their game.  Likewise, a coach should know if there is a significant flexibility limitation or previous injury so that they can appropriately coach and put the golfer in a position to succeed.  This, in a way, is building a swing around the golfer, not trying to make every golfer perform the “ideal swing”.  These reasons, among others, are why the golf coach should build a team around themselves and their student.
      1. Maybe his swing truly is "ideal."  But, perhaps his flexibility and balance is as well!
        Maybe his swing truly is “flawless.” But, his ideal flexibility, power and balance allow him to have that swing!
  2. The Medical Professional 
    1. The final two are what has adapted from the original “physical conditioning” team member in the 1990’s.  The medical professional obviously would lead the way when the athlete is in pain or recovering from injury. However, they also should take the lead in regards to the functional movement assessment.  The physiotherapist (physical therapist) can offer something that no other team member can – manual therapy and therapeutic exercises.  If the golfer is in pain or needs to correct muscle imbalances that are effecting his/her strength or flexibility, the physical therapist can use specific manual techniques to alleviate the dysfunction.  I may be biased, but PT’s are experts in evaluating and treating human movement, and understand where stretching or strengthening can be added to optimize movements specific to the golf swing.  This can be done with the Selective Functional Movement Assessment – a systematic approach to assess fundamental movement patterns to isolate the specific area of the body causing the limitation.  That does not mean that they should write strength and conditioning programs for the golfer.  That is the job of the fitness professional.  But, if the athlete does not have the competency to perform movements related to golf or training, the physio should be consulted.  There is a second key job of the medical professional.  As stated previously, the best coaches understand their athlete’s strengths and weaknesses and build unique to them.  So, another innovative model by TPI is that the medical professional can assess the golfer using the TPI Golf Specific Screen, then consult with the golf coach to allow them to know where their main deficits reside.  This will allow the coach to understand positions and movements that the golfer will have difficulty performing at that time.
  3. The Fitness Professional
    1. Once the athlete has the competency required to partake in a strength and conditioning program (no pain, no major ROM restriction), the fitness professional will evaluate the golfer and implement a physical conditioning program. Strength, balance, flexibility, power, and endurance are all important characteristics for golf performance and injury prevention, and the fitness professional is the best team member for the job.  With the expert knowledge of performance, strength and conditioning and programming to optimize human movement, the strength and conditioning coach is of utmost importance in the training of a golfer.
    2. Don’t just take my word for it, check out this quote from Brad Faxon in an interview with The Wall Street Journal, “A lot of the old guard still blame equipment for the increased distance on Tour, but so much more of it is the quality of the athletes,” Mr. Faxon said. “You don’t have to work out to play on Tour, but if you don’t, you get passed, because you’re not strong enough. And the stuff we do these days is all full-body, functional movement.” The entire article can be found —> HERE.  I encourage you to read it as it piggy-backs this post.

There is not one member of the team that is more important.  They all work in unison to maximize potential by correcting flaws that limit a player’s swing, and improving performance and durability to keep the athlete healthy and strong.

So, if you want yourself, your son/daughter, or your student to reach their full potential in the game of golf, I believe that surrounding him/her with a great team can help to streamline their success.

team

Elbow, Wrist and Hand Injuries in Golf

elbow pain

As previously presented HERE, injuries of the elbow, wrist, and hand are second most common of all injuries sustained by golfers.  Not surprisingly, these injuries are more common in amateurs versus professional golfers.  The flexor and extensor tendons (muscles in the front and back of forearm) of the elbow are particularly susceptible to injury due to the repetitive demands of the golf swing, and the requirement of those muscles to be active during impact with the ball and the ground.

Lateral Epicondylitis (Tennis Elbow). Humerus, Lateral epicondyle, Olecranon, Ulna, Extensor carpi ulnaris, Extensor digitorum, Extensor carpi radialis brevis, Extensor digiti minimi. MendMeShop¨Ê  ©2011

Two main elbow injuries are seen in golfers, medial epicondylitis (Golfer’s Elbow) and lateral epicondylitis (Tennis Elbow).  Interestingly, tennis elbow is as much as five times more common in amateurs than golfer’s elbow! These injuries are most often caused by repetitive use or a single traumatic event like hitting a “fat shot.”  As stated HERE, overuse injuries are usually seen in professionals and competitive golfers because of large practice times, and amateurs usually suffer from trauma especially with improper form or a bad swing.  It is no surprise that the incidence of elbow injuries increase with an increase in rounds of golf per week (especially if its 2 or more rounds per week).

Currently, limited to no research relates physical qualities of the golfer to factors that predispose them to elbow injuries.  However, as with most situations it is important to have full range of motion and strength.  Normal flexibility and sufficient strength typically allows our bodies to be more resilient especially when repetitive stresses are being applied to the same area.  This is analogous to runners having a strong lower body and core as well as mobile hips to attenuate the ground reaction forces being applied from the ground during each stride.

With that said, below are three quick tests that you can use in order to determine whether you have enough wrist range of motion.  Again, this is not exhaustive, so even if you pass these tests but have some wrist/ forearm or hand pain you should be evaluated by a medical professional.

RANGE OF MOTION

  • Wrist Flexion: Click the link —> HERE to perform the screen.
  • Wrist Extension: Click the link —> HERE to perform the screen.
  • Forearm Rotation: Click the link —> HERE to perform the screen.

MUSCLE STRENGTH/STABILITY

It is not within the scope of this post to discuss strength and stability tests of the forearm that would be used in a clinical examination.  Furthermore, there is limited research as to the efficacy behind what is “sufficient strength” and whether or not it reduces the risk of injury.  However, there is some current research that relates decreased shoulder strength/ endurance in individuals with tennis elbow.  View the full abstract —> HERE.

Also, a quick golf specific screen to consider shoulder impairments can be viewed —> HERE.

Again, prevalence and mechanism of upper extremity injuries in golf is relatively well understood; however, there is limited research as to predisposing factors for injury and injury prevention other than improvements in technique in the golf swing.  Hopefully, more research will be performed in the near future.

 

 

 

Golf Injuries: An Overview

golf injuries

The following is an overview of golf injuries including how, why, and who they occur to including comparisons between professional, amateur and the aging golfer.  Furthermore, a brief discussion on risk factors, swing considerations, and injury prevention strategies will be presented.  More detail of each will be presented in future articles, but this general overview serves to develop a background knowledge base for the athlete, parent, coach, fitness and medical professional.  It is quite long, so sit back, grab and Arnold Palmer and hopefully it will expand your knowledge base about injuries in golf.

Introduction

Over the last decade, an increase in the popularity of golf has been well documented.  An estimated 55 million people worldwide participate in the great game of golf!  With that, the number of courses in the USA, Europe, and Asia has increased tremendously.  With this increased accessibility and participation (among other things), an increase in injuries has also occurred.  Golf is usually described as a game that requires mild to moderate activity level; however, injuries in golf should not be underestimated or undervalued.  Additionally, many mechanisms and characteristics of injuries appear to be consistent with different skill and age groups who participate in the game.  Having an understanding of these consistent occurrences should facilitate the decision making process on developing strategies for prevention, rehabilitation, and enhancement of golf performance.

Golf Injuries in General

In general, golf injuries originate from either over-use or from a single traumatic event, and primarily affect the low back and upper extremity.  Amateur golfers have an annual prevalence of between 25.2-62% (1.19-1.3 per golfer per year), and the main risk factors appear to be low handicap and age over 50 years old.  On the other hand, in the professional golfer, it is closer to 88% or 2.0 injuries per golfer per year.  The higher prevalence in pro golfers is likely due to the increase practice times and repetitive nature of the game.

There are slight differences in regards to body parts affected, but in general the most common sites for injury are: Low Back (28-35%), Elbow (25-30%), Hand/ Wrist (15%), Shoulder (10%) followed by the lower extremity equally (hip, knee, ankle).

Who is at Risk for Golf Injuries?

Two primary groups of golfers are at risk for injuries: amateur golfers comprising of recreational and occasional, as well as professional golfers.  Occasional golfers are documented to be prone to injuries related to a poor knowledge of execution of golfing skills, resulting in traumatic injuries (usually at impact) or injuries related to badly executed golf swings.  In addition, amateurs in general are prone to overuse injuries due to various behaviors such as lack of warm-up, reduced mobility/ flexibility, limited strength, lack of physical conditioning, etc.

Competitive golfers (professionals and highly skilled amateurs) usually report soft tissue and musculoskeletal injuries associate with overuse.  This is usually due to the repetitive nature of the golf swing with intense or long practice sessions that cause imbalances in strength and range of motion predisposing these players to overuse syndromes.

Additionally, older golfers are considered “higher than normal risk” for injuries not only due to the nature of the game but also physiological factors associated with aging.

Injuries by Anatomical Location

Low Back and Trunk: As stated previously, the most commonly injured area is the low back.  However, reduction in participation was no more than one month for any episode of low back pain, and the most common injuries were minor which resulted in only one week of practice lost. Furthermore, the number of golfers with a history of LBP may be as high as 55% but it is unclear as to whether it is due to golf practice alone. Author’s note: This is consistent with orthopedic research regarding low back pain, which is said to be self limiting and resolving on its own in the majority of cases in 4-6 weeks.  Interestingly, the area of the body that has the largest practice time lost due to injury is the thoracic spine and not the lumbar spine.

Upper Extremity: Elbow injuries are the second most common, and moreso in amateur golfers than professional.  Medial epicondylitis (Golfer’s Elbow) occurs most in the right arm (for right handed golfers) usually due to repetitive resisted forces or from a single traumatic event like striking the ground and taking too large of a divot.  Lateral epicondylitis (Tennis Elbow) also affects amateurs more than pros, and occurs in the leading elbow.  The incidence of both conditions increases when the frequency of golf is increased (i.e. >2-3 rounds per week).  Interestingly, in amateurs Tennis Elbow is more prevalent than Golfers elbow!

Shoulder injuries are the third most common across the board, and most often related to overuse injuries due to excessive shoulder rotation at the top of the back swing and in the follow through.  In all reports, the leading shoulder was more commonly injured resulting in AC joint problems, impingement, rotator cuff tendonitis/ tears, instability, or arthritis.  Finally, wrist and hand injuries occur especially during forceful swings with high impact on the ground.

Lower Extremity: Lower limb injuries are no very prevalent in golfers, but it should be noted that the literature on the occurrence and mechanisms is limited.

Injury Distribution by Age

The average age for occasional golfers in the USA is 45 years old and one third of all American golfers are 50 years of age or older.  Not surprisingly, golfers 50-65 years old have the highest injury prevalence.  The reason for this is due to physiological changes that occur with aging such as changed in the musculoskeletal, cardiovascular, and neural systems.  Decline in strength, flexibility, coordination, bone and tendon resiliency and ability to deal with stress may increase rate of injury.  Author’s Note: This is another area of importance for the benefit of exercise in golf, but it is not the scope of this review and will be discussed later.  However, it should be noted that many of these declines in the aging adult can be mitigated with consistent resistance training due to the fact that type II muscle fiber (fast twitch) declines with age.  It is well documented that reduction of power and strength occur with normal aging, and with that a reduction in club head speed (golf’s demonstration of power) occurs between ages 40-59.

Mechanisms of Golf Injury

In amateurs that play an average of 2 rounds per week were most often injured by overuse, striking the ground with the club (hitting it “fat”), and poor swing mechanics.  Over-swinging, poor or incomplete warm-up, twisting of the trunk during the swing, and gripping too tight are other potential causes.  In professionals, overuse accounts for 80%, hitting it fat was 12%, and twisting of the trunk was 5%.  Professional golfers have almost negligable injuries due to poor swing mechanics, over-swinging, poor warm-up, or grip/swing changes.

Injury Versus Handicap

As mentioned several times, there are differences between professional and amateur golfers.  Professionals partake in regular competition and follow intense organized schedules of practice.  However, they are also usually engaged in carefully structured conditioning programs, and have better strength and flexibility indicators than recreational golfers.  Authors note: It is well documented that skill and fitness enhancement can reduce the risk of injury in other sports, why is it so hard to believe that golf would be any different? Spoiler alert…there is no difference!

Okay back the the details.  This next sentence is music to my ears!  Many problems detected in the amateur player  would probably disappear if a new and improved technique were adopted.  At the peak of the backswing, pro players were shown to exhibit significantly higher left shoulder horizontal adduction and right shoulder external rotation.  Professionals also have more trunk rotation at the height of the backswing and at the moment of ball contact.  How can you tell if you have enough trunk rotation? Click —> HERE.

Furthermore, low-handicap golfers who suffer LBP tend to demonstrate reduced erector spinae activity at the top of the backswing and impact, yet greater external oblique activity throughout the swing.  These findings are consistent with the “reverse spine angle” and “inverted-C” patterns.  More detail on these patterns are discussed —> HERE.  To piggy-back this idea, it is thought that this increased side-bending and early lumbar extension is a compensation from limited trunk rotation and frequently observed in recreational players.

Overall, low handicap golfers are injured more frequently than high handicappers, but the mechanisms and types of injuries are different.

Swing Phases and the Incidence of Injuries

With the understanding of how high club head velocities need to be reached in a short amount of time, it is easy to see that high stresses are applied to the body which can cause overuse or traumatic injuries.  Most articles separate the swing into several phases: (1) Ball Address, (2) Back-swing, (3) Down-swing, (4) Impact, (5) Follow-through.

Note the extreme ranges needed in the hips, shoulders and trunk!
Note the extreme ranges needed in the hips, shoulders and trunk!

With that said, most injuries occur at the end of the down-swing (18%) and follow-through (42%).  Many authors credit this to the high forces when the club is contacted with the ground and place emphasis on forearm muscle strength to maintain control of the club.  However, injuries may occur in any phase of the swing.

(1) Ball Address and (2) Back-swing: Ball address is characterized by adopting an optimal pre-stroke posture which may be different for some golfers but is generally an athletic stance with a neutral spine (flat back).  This posture will allow the golfer to generate maximal potential energy.  Structures may be stressed due to compromised starting position including: excessive loading of the spine through hyper-extension.  During the back-swing, shoulder injuries can occur through compression of the rotator cuff or sub-acromial bursa, or from instability of the lead shoulder.  Likewise, over-rotation of the trunk during the back-swing can cause injury.

(3) Down-swing and (4) Impact: It has already been established what forces occur during impact and the effects on the wrist/hand/elbow, yet the downswing has not been discussed.  Injuries during the downswing (and even impact) occur in the range of movement of greatest muscle activity.  Players who are less skilled have up to 50% less trunk rotational capacity than younger more skilled players.  This means that to compensate and be able to hit the ball as far, a higher muscle activity will be demonstrated.  Thus, higher loading of the spine is a result due to reduction in flexibility, strength and stabilization of the trunk/ spine.  This is another important reason for optimizing mobility and stability (i.e. strength and conditioning).

(5) Follow-through: During the follow through there is a rotary motion of the hip and shoulders so that the body faces the target.  With this, the lumbar spine is at risk for injury if the deceleration stops too briskly or if the final motion is too pronounced (ex. reversed “C” or over rotation).  To minimize excessive spinal load the spine should be vertical at the end of the follow through.

As for the shoulder musculature and rotator cuff in particular, the supraspinatus and infraspinatus of the lead arm are activated primarily during follow through, while the subscapularis remains active during the forward swing and ball impact.  Thus, these muscles are not only important for stabilizing the shoulders during the swing, but also during the follow through.

Summary

  • The general nature of the golf swing and subsequent injuries is quite similar among golfers.
  • Recreational golfers are more likely to suffer traumatic injuries from bad technique, insufficient warm-up and poor physical fitness.
  • Competitive and professionals are usually affected by overuse injuries which stem from strength and range of motion imbalances.
  • Low back pain is the most common complaint but its not clear if it is related to golf practice.  Find out more here.
  • Shoulder problems are also common, with the lead shoulder being more often reported.
  • Elbow injuries are second most common, with tennis elbow being more prevalent than golfer’s elbow.
  • Traumatic and impact injuries are more common in young or old players, and players with low skill levels.

If you enjoyed this post, but are interested in more detail about specific injuries and their prevalence in golfers, we have you covered!

Low Back Pain —> HERE

Shoulder Injuries —> HERE

Elbow/ Wrist/ Hand Injuries —> HERE

 

 

 

 

 

References

Cabri J, Sousa JP, Kots M, Barreiros J.  Golf-related injuries: A systematic review.  European Journal of Sport Science. 2009; 9(6):353-366.

Shoulder Injuries in Golf

golf-shoulder-pain

Shoulder pain and injury is consistently cited as the third most common injury among golfers.  This statistic has lead many researchers to conduct studies and formulate correlations between shoulder injuries, physical characteristics of the golfer and swing faults. Furthermore, it is not within the scope of this post to review the anatomy and pathophysiology behind different medical diagnoses (ex. rotator cuff tear, sub-acromial impingement, etc.) in regards to shoulder pain.  However, it has been well documented that treatment should not performed with only the medical diagnosis in mind and that each individual should be evaluated. The following is a summary of different mechanisms that have been found to contribute to shoulder pain in golfers.

RANGE OF MOTION

  • Shoulder Elevation: Optimal shoulder elevation is 170-180 degrees.
    • Many compensations will be viewed if this is less than optimal.  A basic screen is —> HERE.
    • Note: Do not let the name of the screen fool you.  If you are find a deficit in this test, it does not always because of tight lats.
  • Shoulder Horizontal Adduction: Optimal shoulder horizontal adduction is 135 degrees.
    • A good demonstration of horizontal adduction is located —> HERE.  The elbow of the moving arm (left arm of the subject in the video) should be able to at least cross midline.  However, be aware of hyper-mobility and its implications with instability.
  • Shoulder External Rotation: Optimal shoulder external rotation is 90 degrees.
    • Here is a great golf specific screen for shoulder rotation —> HERE.
  • Trunk Rotation: Optimal trunk rotation is 50 degrees in each direction.  It is necessary to understand that optimal trunk mobility is important in shoulder health because of the intimate relationship between the trunk and the shoulder blade.
    • Want to test your own trunk rotation? Click —> HERE.

MUSCLE STRENGTH/ACTIVATION

No isolated tests have been researched that correlate to reduction of shoulder injuries in golf.  However, understanding muscle activity during the golf swing can serve as a basis for training and improvement of the swing mechanics, so that selective strengthening and rehabilitation of shoulder musculature can take place.  This is important not only to optimize function and protection of the joints, but to reduce imbalances from the repetitive nature of the golf swing.

  • Rotator Cuff Muscles: FYI, several clinical studies have found that there is no difference in the activation of these muscles in men and women.  This is most likely due to the consistent nature and demands of the golf swing.
    • Supraspinatus and Infraspinatus of the Lead Shoulder: demonstrate low activity during the swing with peak activity occurring at take away and follow-through.  These muscles act as abductors and external rotators to help stabilize the shoulder joint.
    • Subscapularis: The most active of the rotator cuff muscles showing activity during most of the swing especially during the acceleration phase of the down-swing.

rotator cuff muscles

  • Scapular Stabilizers: These muscles are also very important in the health of the shoulder in golfers.
    • Latissimus Dorsi and Pectoralis Major: Most active of all shoulder muscles, with the lat acting maximally in the down swing and acceleration phase.
    • Deltoid: Interestingly non-active except for the anterior deltoid during the follow through to help with shoulder flexion.
    • Trapezius: helped to retract the lead shoulder during the down-swing and acceleration phases, whereas it was active in the trailing arm during the back-swing.
    • Rhomboid and Levator Scapulae: were active for retraction during the backswing and control of protracting during the down swing (especially on the right).
    • Serratus Anterior: acted as a scapular protractor and demonstrated peak activity during the downswing and follow through phases of the trailing arm.  In the lead arm, it demonstrated low synchronized activity throughout the swing which may explain why it is susceptible to fatigue in some golfers.

scapula-mm

The lead shoulder (left shoulder in right handed golfer) has been found to be injured 3x more than the trail shoulder, and more recently, it has been reported that more than 90% of shoulder problems in golfers occur on the lead side.  During the backswing, the lead shoulder undergoes internal rotation, flexion, and horizontal adduction which can exacerbate certain types of conditions.  Conversely, during the down swing it undergoes abduction and external rotation.  A thorough history, clinical evaluation and symptom response are of utmost importance for isolating the shoulder dysfunction that is causing pain.  However, in simple terms it is important to optimize mobility/ flexibility and stability/ strength to protect the shoulder and torso against such high demands of motion and force.

As discussed —> HERE, low back pain and range of motion deficits (especially on one side) correlate to improper function during the golf swing.  Similarly, shoulder range of motion and strength deficits may be found on one side of the body versus the other.  This is due to the repetitive one sided nature of the golf swing.  Furthermore, the above information (especially in terms of range of motion) would be optimal on both sides of the body; however, emphasis should be placed on one side versus the other depending on the handedness of the golfer.  Likewise, an understanding of the above information can facilitate the evaluation of muscle imbalances in golfers which may lead to decreased performance and even injuries.

 

 

 

 

 

Resources

Kao JT, Pink M, Jobe FW, Perry J. Electromyographic analysis of the scapular muscles during a golf swing. Am J Sports Med. 1995;23(1):19-23.

Kim, David H., Millett, Peter J., Jobe, Frank W. “Shoulder Injuries in Golf.” The American Journal of Sports Medicine 32.5 (2004): 1324-330. Web.

Low Back Pain in Golf

golf low back pain

Low back pain (LBP) is consistently cited as the most common injury among golfers.  This statistic has lead many researchers to conduct studies and formulate correlations between LBP, physical characteristics of the golfer and swing faults.  However, it should be noted that many authors admit that LBP is a multifaceted condition that is difficult to control in scientific research. Furthermore, it is not within the scope of this post to review the anatomy and pathophysiology behind different medical diagnoses (ex. disc herniation, muscle strain, etc.) in regard to low back pain.  However, it has been well documented that treatment should not performed with only the medical diagnosis in mind and that each individual should be evaluated.  With that said, the following is a summary of different mechanisms that have been found to contribute to low back pain in golfers.

RANGE OF MOTION

  • Hip Internal Rotation: It has been concluded that decreased lead hip IR may contribute to LBP in golfers.
    • This was found in both pros and amateurs.
    • Reduced hip IR may cause compensation of over rotation of the trunk.
    • Likewise, improving lead hip IR has been found to reduce low back pain (Grimshaw and Burden, 2000)
    • To start the process of testing your hip internal rotation click —> HERE
  • Hip External Rotation: There is an established correlation between decreased lead hip FABER range of motion and LBP.
    • This was only for professional golfers, but not for amateurs.
  • Non-Lead Hip Range of Motion:  No correlation in amateurs or professional golfers.
  • Lumbar Extension:  Decreased lumbar extension has been shown to correlate to a history of LBP.
    • The test for this is an easy one.  Lay on your stomach (prone) and place your hands under your shoulders as if you were going to do a push-up.  Without lifting your pelvis off of the table, straighten your arms as if to stretch your back.  If you are unable to full extend your elbow (or come close to it) without having your pelvis rise off of the ground, you have limited lumbar extension.
  • Lumbar Flexion: There was no correlation between decreased lumbar flexion ROM and a history of LBP.
  • Trunk (Thoracic) Rotation: Golfers with LBP have less rotational flexibility in the trunk (Lindsay and Horton, 2002).
    • How can I test my trunk rotation?  Glad you asked.  Click —> HERE.
    • The test video from TPI does not fully isolate the thoracic spine, but it can tell us if we need to assess further to isolate the thoracic spine.
  • Toe Touch: An inability to perform a toe touch was also related to LBP in one article.  To see how to perform this test click —> HERE.

SWING FAULTS

  • Reverse Spine Angle: Usually a compensatory pattern that results from decreased hip or trunk rotation (see above).
    • For an example of this swing fault, check out this video from TPI —> HERE.
  • S – Posture: In the world of orthopedics, this is also called lumbar lordosis.  It has also been coined “lower-crossed syndrome.”
    • This posture places the lumbar spine in hyper-extension and a video example is —> HERE.
  • C – Posture: This is a posture that places the lumbar spine in flexion.
  • Hanging Back: Considered to be a potential swing fault for various reasons, I find it is due to lack of lead hip internal rotation or lack of stability/ balance on the left leg.
    • This lack of hip internal rotation or stability decreases the player’s ability to transition to the lead side and complete the follow-through.
    • A great demonstration is found —> HERE.
  • Early Extension: Another swing fault due to reduced lead hip internal rotation.  There are physical parameters and screens that correlate to this swing fault.  However, here is an in depth overview of this swing fault —> HERE.

MUSCLE STRENGTH/ STABILITY

Even though range of motion and technique is very important in the golf swing to protect the spine, we cannot forget about strength and stability in the lower extremity and core.  It is well documented that strength and power can improve performance, but we need to remember that it can also reduce the risk of injury.  Without going into excessive detail, the lower body and core should have adequate stability in order to attenuate considerable amounts of load on the spine during the back-swing, impact, and follow through.  Several tests can be helpful to detect core and lower extremity stability deficits.

  • Single Leg Stance: a test for overall balance that can highlight any side to side asymmetries —> Click HERE.
  • Bridge with Leg Extension Test: a great test for lumbo-pelvic-core stability especially gluteal function is shown —> HERE.
  • Trunk Stability Push-Up: tests the ability to stabilize the spine in an anterior and posterior plane during a closed-chain upper body movement.  An overview of this test is —> HERE and reasons why its important are —> HERE.

 

 

 

 

 

 

Resources

Grimshaw, P., Burden, A. M. (2000). Case Report: reduction of low back pain in a professional golfer.  Medicine & Science in Sports & Exercise, 32, 1667-1673.

Lindsey, D., Horton, J. (2002). Comparison of spine motion in elite golfers with and without low back pain. Journal of Sports Science, 20, 599-605.

Murray E, Birley E, Twycross-Lewis R, Morrissey D. The relationship between hip rotation range of movement and low back pain prevalence in amateur golfers: an observational study. Phys Ther Sport. 2009;10(4):131-135.

Vad, V. B. (2004). Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits.  American Journal of Sports Medicine, 32, 494-497.