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.

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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

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.