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A Physiotherapy Perspective on Improving Swing Technique in a Professional Golfer a Case Study

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  Case study A physiotherapy perspective on improving swing techniquein a professional golfer: a case study Lynn Booth * English Ladies Golf Association, Edgbaston Golf Club, Church Road, Birmingham B15 3TB, UK  Received 15 July 2004; revised 24 January 2005; accepted 30 January 2005 Abstract Providing information regarding the use of physiotherapy or related musculoskeletal conditioning to improve a sporting technique requiresexperience of the sport in question, and knowledge of relevant research evidence and functional anatomy and their application to the sport.Physiotherapists and other rehabilitation providers working with athletes must also ensure that they are working to the specific requirementsof the athlete and coach.This case study outlines the effect of physiotherapy intervention over a 2-year period on the swing of a professional golfer. The essentialcomponents required to produce a good result when treating sports injuries are highlighted. Such components include a detailed discussionbetween the golfer, coach, and physiotherapist, the use of digital performance analysis, and the application of relevant musculoskeletalprofiling. Taking this approach provides a platform on which to devise an appropriate exercise intervention. q 2005 Elsevier Ltd. All rights reserved. Keywords:  Golf; Musculoskeletal profiling; Sports injuries; Sports skills 1. Introduction After 7 years experience of working with regional,national, junior, and adult elite amateur golfers, I wasapproached by a Professional Golf Association (PGA)coach to provide an opinion on whether any aspect of physiotherapy or related musculoskeletal conditioningcould improve the swing technique of a 30-year-old femaleprofessional golfer.The golfer, a naturally right-handed player who playedwith right-handed clubs, played on the Women’s EuropeanTour and frequently received physiotherapy treatment andmassage, mainly for the upper limbs and cervico-thoracicspine, from physiotherapists working on the Tour and in herlocal region. Due to the constant travelling to competitions,however, the golfer was seldom at home long enough forunderlying causes of injury to be identified and adequatelyaddressed.The golfer and her coach had decided that the priorityduring the winter (non-competitive) training season wouldbe to modify her swing, in particular to develop a betterswing plane. Observing the golfer work with the coach,followed by a musculoskeletal profiling session, highlightedseveral areas that might benefit from physiotherapyintervention. In general, these were a kyphotic thoracicposture, reduced thoracic mobility, reduced stability andcontrol of scapulothoracic and lumbopelvic regions, andweak lateral rotator cuff and abdominal oblique muscles.These areas of concern are detailed more specifically underthe assessment section of this paper. In order to fullyunderstand the relationship between the golf swing andphysiotherapeutic methods a brief review of relevantliterature follows. 2. Review of literature Reviewing relevant papers on common golf injuries (e.g.Batt, 1992, 1993; Brendecke, 1990; Burden, Grimshaw, &Wallace, 1998; Burdorf, van der Steenhovenm, & Tromp-Klaren, 1996; McCarroll, Rettig, & Shelbourne, 1990;Metz, 1999; Nissinen et al., 2000; Seaman, 1998; Theriault Physical Therapy in Sport 6 (2005) 97–102www.elsevier.com/locate/yptsp1466-853X/$ - see front matter q 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.ptsp.2005.01.003 *  Tel.: C 44 7770 236 226. E-mail address:  physiolynn@aol.com.  & Lachance, 1998) helped to define the areas that should beconsidered during the physiotherapy musculoskeletalassessment.Batt (1993) and Pink, Jobe, and Perry (1990) describedthe mechanics of the golf swing as requiring rapidglenohumeral movement through a large range of move-ment, necessitating an intact and functioning rotator cuff firing in synchrony to provide a coordinated movement toprotect the glenohumeral complex. At the top of thebackswing the left arm of a right-handed golfer is inmaximal horizontal adduction and internal rotation.Although shoulder elevation during the golf swing is notusually greater than 90 8  in either shoulder until the end of the swing, anterior joint line pain may be indicative of impingement of the humeral head against the anteriorlabrum (Jobe & Pink, 1996). Muscles responsible forscapulae stabilisation have an important role in preventingimpingement (Regan, 1996). Batt (1992) reported that shoulder injuries only accounted for 2% of the total injuriesof 193 amateur golfers. However, the golfers in Batt’s(1992) report represented only a 42% response rate from onegolf club with an average age of 38.5 years and an averagehandicap of 10.2. Studies on professional golfers have foundthat the back, wrist, and shoulder were the most commoninjury sites (McCarroll & Gioe, 1982), the injuries wereusually overuse in nature and right-handed golfers had morefrequent problems in the left upper limb (Theriault &Lachance, 1998). Jobe and Pink (1996) reported only 98 new shoulder injuries (7.7%) in a 5-year period althoughthis was on the Seniors PGA Tour, where golfers were 50years and older.In a series of studies by one research group (Jobe,Moynes, & Antonelli, 1986; Jobe, Perry, & Pink, 1989; Pink et al., 1990), it was identified that the muscle work requiredaround the shoulder complex during the golf swing inprofessional golfers was no different between men andwomen in relation to the firing patterns of normal shouldermusculature. A search of the literature has not identified anystudies detailing the muscular firing pattern in the shouldersof injured golfers.From extensive experience in working with eliteamateur golfers it is evident that, although acutetraumatic shoulder injuries do not commonly occur,several elite (junior and adult) amateur golfers didcomplain of chronic shoulder injuries. Jobe et al. (1986)suggested that there might be more erratic firing of therotator cuff muscles in amateur golfers compared toprofessional golfers. This does not reflect my ownexperience that both amateur and professional golferscomplain of shoulder problems. It could be that Jobeet al.’s (1986) definition of ‘amateur golfers’ actuallyrefers to recreational golfers rather than elite amateurs. Asrefining the swing plane of the golf swing is a constantcoaching point for both amateur and professional golfers,the importance of shoulder girdle and glenohumeralcontrol could not be overlooked.Pinketal.(1990)suggestedthatasagolferusesbothsidesof the body in synchrony, right-handed golfers shouldstrengthen the left rotator cuff muscles to at least the levelsoftherightshoulder.Exerciseprogrammesforgolfersshouldinclude bilateral strengthening of the rotator cuff muscles toprovide a coordinated and protected movement during therapid, but not necessarily strenuous, arm activity. Biannualmusculoskeletal profiling of golfers by chartered phy-siotherapists working for the English Ladies Golf Associ-ationandtheEnglishGolfUnionhasshownthat,incommonwith other sports, the lateral rotator cuff muscles (infra-spinatus and teres minor) tend to be weaker than the medialrotator cuff (subscapularis) (Codine, Bernard, Pocholle,Benaim, & Brun, 1997; Hall, Milligan, & Stewart, 1995).An effective and efficient golf swing, that reduces thepropensity for injury, requires the spine–hip angle to remainconstant, which in turn requires good trunk and hip rotation(Booth & Forrest, 1999). Golf coaches use the term ‘spine–hip angle’ to refer to a combination of spine/pelvis andpelvis/thigh angles. Booth and Forrest (1999) suggested thatin order to enhance performance and reduce the likelihoodof low back pain, golfers must try to attain 90 8  trunk rotationin both directions in sitting.In common with other sports, golf coaches differamongst themselves on the technical aspects of the golf swing, and it is important that physiotherapists and otherrehabilitation providers working with golfers and coachesensure that they are working to the coach and golfer’sspecific requirements.The author’s experience of musculoskeletal profiling of elite amateur golfers had highlighted several commonthemes, which were considered when assessing thisparticular golfer. These themes included: †  At the address position (the stationary position before thegolfer starts to move the club), the right hand is lowerthan the left on the shaft of the club resulting in the rightshoulder being lower than the left. This habitual postureresults in some golfers demonstrating a scoliosis concaveto the right in standing, and many golfers show tightnessof the left upper trapezius and left levator scapulae withassociated lengthening of the right upper trapezius. †  Despite being able to demonstrate good thoracic rotationsomegolfersstilltendtolosethespine–hipangleortoturnthe whole body rather than just the trunk. The study byBechler,Jobe,Pink,Pery,andRuwe(1995)highlightedthemuscle work in the hip and knee during the golf swing,showinga sequentialfiringofmuscles thatgeneratepowerfrom the lower limbs through the trunk to the upper limbs. †  Whiteley (1999) suggested that higher handicap golfers,in an effort to increase the ball-flight distance, try togenerate extra power from the muscles of the shouldersand arms rather than the trunk. In the author’s experiencethe same applies to elite amateur golfers, thus placingadditional strain on the stabilisers of the scapulae andglenohumeral joints. Mottram (1997) and Regan (1996)  L. Booth / Physical Therapy in Sport 6 (2005) 97–102 98  highlighted the importance of static and dynamicscapulae setting and discussed basic scapular stabilisingexercises that should allow golfers to control the golf club during the swing. †  Amajorityofgolfershavepoorenduranceandstrengthinthe muscles of the lateral rotator cuff compared to themedialrotatorcuffmuscle,particularlyintheleftshoulder.Voight, Hardin, Blackburn, Tippett, and Canner (1996)suggested that treatment protocols should emphasisemuscle endurance as shoulder proprioception (the abilityto reproduce a pre-established position) is diminished inthepresenceofshouldermusclefatigue.Scoville,Arciero,Tayloy, and Stoneman (1997) suggested that the ratio of eccentric lateral rotator cuff muscles to concentric medialrotatorcuffmusclesinasymptomaticmaleswas1.08:1and1.05:1 in dominant and non-dominant shoulders, respect-ively.Theirstudy,however,hadseveralshortcomings;thesubjects had their upper body fixed by restraining straps,the shoulders were only tested between 90 8  of lateralrotation and 20 8  of medial rotation (not end-range formedial rotation of the shoulder), and the isokinetic speedwas set at 90 8  /s. Increasing the speed and extending theleverbyusingagolfclubwouldbeexpectedtoincreasetheratio. Ellenbecker (1996) demonstrated that isokinetictesting of the medial and lateral rotators of the shouldershowed significant differences in subjects with normalgrade strength measured using manual muscle testing.However, the study used isokinetic speeds of 210 and300 8  /s (far too slow to mimic a golf swing) and isometricmanual muscle testing. †  In the absence of an objective test of rotator cuff strengththat can be used ‘on the range’ rather than in a laboratory,theauthorisstillassessingmusclestrengthsubjectively—using testing procedures suggested by Kelly, Kadrmas,and Speer (1996), who used EMG (surface and indwel-ling)onthenon-dominantshouldersof11normalsubjectsto establish the optimal manual muscle test for the rotatorcuff muscles, although there is no mention of teres minor. †  Although there is no research using randomised con-trolled trials to support the claim, many peopleassociated with golf (players, coaches, support staff)suggest that improved lumbar/pelvic stability results inimprovement in ball-flight distance. †  To reduce the strain on the upper limbs (Whiteley, 1999),and in line with the findings of  Watkins, Uppal, Perry,Pink, and Dinsay (1996), golfers require trunk rotatorstrength in outer range. 3. Initial contact 3.1. Assessment  The golfer’s local physiotherapist had suggested that thegolfer’s posture was too kyphotic, that she had poor weighttransference, was over-rotating her upper thoracic spine toachieve distance during a full swing, and hyperextendingher upper cervical spine to get her eyes over the ball whenputting. The golfer’s posture and abdominal control hadsubsequently benefited from Pilates intervention.It was important to review the golfer’s swing with thePGA coach using high-resolution digital cameras andelectronic software. This allowed the swing action to beevaluated in both sagittal and coronal planes and at normaland slow speeds. Subsequent detailed discussion of theswing dynamics and the physical demands being placed onthe golfer allowed interpretation of the coach and playerrequirements, and provided a platform on which to deviserelevant musculoskeletal assessment and exerciseintervention.Digital analysis of the swing showed that the golfer didnot over-rotate the thoracic spine during the swing butactually over-protracted the left scapula. This fault hadprobably developed to compensate for a lack of right trunk rotation whilst still attaining the correct position of the clubhead at the top of the backswing, and could explain therecurring pain in the left scapula and upper arm, which hadcaused the golfer to seek treatment during the season.Using information from the relevant literature andprevious experience, the musculoskeletal assessment wascarried out. Salient points from the assessment of the golferincluded: †  Established kyphotic thoracic posture †  Sitting trunk rotation; right Z 75 8 , left Z 70 8 †  Reduced scapulae stability and control; left O right †  Weak concentric lateral rotator cuff muscles compared toconcentric medial rotator cuff; left and right †  Poor lumbar/pelvic stability †  Very weak outer range abdominal oblique muscles; leftand right †  Pain and stiffness on palpation of T5-7 centrally. 3.2. Treatment  A regime of exercises was developed to address theissues found on assessment. In particular, emphasis wasplaced on the importance of improving trunk rotation(Booth & Forrest, 1999), lumbar/pelvic control, andscapulae stability and control (Moseley, Jobe, Pink, Perry,& Tibone, 1992). Moseley et al. (1992) used EMG analysis on nine healthy subjects with no shoulder pathology toevaluate exercises in their ability to strengthen the scapularmuscles. For this golfer, the exercises suggested by Moseleyet al. (1992) were modified to avoid glenohumeral flexionabove 90 8  to reduce the risk of impingement of the humeralhead against the anterior labrum. The range of shoulderflexion was slowly increased as the concentric lateral rotatorcuff strength improved. A resistance cord was also used tostrengthen the lateral rotator cuff muscles, in order todevelop the posterior ‘biased’ shoulder described by Davies  L. Booth / Physical Therapy in Sport 6 (2005) 97–102  99  and Dickoff-Hoffman (1993). Although golf is an openkinetic chain exercise for the shoulder joint, both open andclosed kinetic chain exercises were used to help developdynamic stabilisation of the scapulae and glenohumeral joints based on the suggestions by Wilk, Arrigo, andAndrews (1996). As well, the progression of exercisesdeveloped by Sahrmann (2002) was used to introducetransversus abdominis into the golf swing to enhance thegolfer’s spinal stability and control.Within six weeks of starting the exercise regime, thegolfer was able to incorporate some muscle control ataddress position, and was aware of the need to continue towork on the programme in order to improve muscularcontrol during the swing. 4. Two years later After a further two seasons on the European Tour, theplayer requested another assessment prior to commencingher winter training programme. She was still working onswing modifications and had experienced chronic injuryproblems with her right shoulder during the previous season.According to the player, an ultrasound scan had showninflammation (but no tear) of the biceps tendon and anorthopaedic surgeon had injected the shoulder (specific sitenot known) three months previously with initial relief.After resting for three weeks she had played on the Touralthough did not recommence any upper body conditioningwork. The golfer had then been provided with a series of shoulder exercises, including ‘core exercises and resistancecord work’. After performing the exercises for one week thegolfer started to complain of pain in the right biceps tendonand muscle, but nevertheless started a weights programmeincluding chest press, upright rows, shoulder abduction, andlat pull downs. Local treatment (ultrasound, interferential)had failed to resolve the right shoulder and upper arm painand four days prior to the assessment the golfer had stoppedplaying after 10 holes due to pain around the insertion of deltoid. Importantly, the golfer admitted that once thecompetitive season had started, she had neglected theexercise regime developed 2 years previously. 4.1. Assessment  A thorough assessment as again carried out. Salientpoints from this assessment included: †  Kyphotic upper thoracic spine with poking chin—in hergeneral and golf posture †  Good lumbar/pelvic control †  Tightness in left upper trapezius muscle †  Lengthening of right upper trapezius muscle †  Sitting trunk rotation; right Z left Z 85 8 †  No abnormalities were detected in the cervical spine †  No weakness of upper arm muscles †  Reduced scapulae stability and control; right O left †  Medial rotation of the right shoulder Z 30 8 . This wasmeasured from the neutral position for rotation (i.e. lyingsupine, with 90 8  glenohumeral abduction, elbow flexedto 90 8 , and the forearm vertical) (Herrington, 1998).Medial rotation of left shoulder Z 50 8 †  Very weak posterior rotator cuff muscles in eccentricouter range; right O left. This would be required tocontrol the glenohumeral joint as the range of shouldermedial rotation improved.It became apparent that the golfer was ‘trying too hard’ tocorrect her scapulae posture and was using the larger phasicmuscles of the upper back rather than the postural controlmuscles of the scapulae—the substitution strategies dis-cussed by Mottram (1997). However, Mottram (1997) also suggested that with increasing loads (long limb lever) thescapulae stabilisers must work above 30% of theirmaximum voluntary contraction, although no evidence isprovided. The resistance cord work for the right shoulderhad been forcing the shoulder beyond its physiologicalrange of medial rotation. This could have an effect onanteroposterior translation of the humeral head (Branch,Avilla, London, & Hutton, 1999; Davies & Dickoff-Hoffman, 1993; Kamkar, Irrgang, & Whitney, 1993),although Branch et al.’s (1999) study, which demonstratedthe relationship between the length of the posterior capsuleand humeral translation during medial rotation, wasundertaken on cadavers (i.e. without muscular control). 4.2. Treatment  Using video analysis, and together with the coach, thenecessity to improve scapulae stability, general and golfingposture, the range of right shoulder medial rotation, and theeccentric strength of the posterior rotator cuff muscles wasstressed to the golfer. Slow motion video also highlightedover-contraction of the right upper fibres of trapezius at thetop of the backswing, which changed the direction of theswing plane—for this reason it was decided not to includestrengthening exercises for the right upper trapezius in theexercise programme.The lack of consistent improvement over the previous sixmonths and the golfer’s realisation that her game was beingcompromised meant that she was more amenable tocommitting to a relevant exercise programme. The golfer’srehabilitation was modified. The recent weights andresistance cord work were stopped and the followingexercises were commenced: †  Mobility exercises for B  Posterior capsule of the right shoulder (Branch et al.,1999) B  Medial rotation of the right shoulder in 90 8  abduction †  Active stretching of left upper trapezius and levatorscapulae  L. Booth / Physical Therapy in Sport 6 (2005) 97–102 100
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