If you have been following my articles, you see by this title that I'm taking a break from the posture analysis theme. [Part 9 of Dr. Tucker's ongoing series on posture evaluation / correction appeared in the Aug. 26 issue.] I enjoy writing about so many different topics within our profession, and also think I have "writers ADD" right now when it comes to posture. I definitely have "exercise ADD," because I'm constantly changing my exercise routines and programs. I have not abandoned the posture theme altogether, as you'll see later on in this article.
The goal when it comes to treating golfers is to give them the ability to play golf "full out." To do that, we have to understand what stops them from playing it that way in the first place. When an injured golfer comes in, the goal of treatment is to have them return to golf (competition) physically and mentally robust in as short a period as possible. Walking 18 holes and spending time on the driving range is not enough to keep golfing muscles in top shape and minimize the risk of injury. It takes relatively strong, flexible golfing muscles to play it well, make improvements and avoid common injuries.
Golf Mechanics and Injuries
The most common injury sites for golfers are the low back, shoulder, knee, elbow and wrist. Golfers who have low back pain demonstrate a decrease in range of motion for hip internal rotation on the lead leg (left leg for a right-handed golfer) and lumbar extension and decreased activation and/or timing of the abdominal obliques, erector spinae and knee extensors.
When we sustain an injury, the brain focuses increased attention on the harmed area. The brain is looking after us because it perceives that the threat of further injury (or re-injury) is still high. I often have patients come in and say something like this: "It doesn't hurt anymore ... but it feels different" or "I'm aware of it." I understand that the brain is keeping tabs. This can lead to anxiety (poor skill execution, poor movement patterns).
I liken it to a process of increasing the number of TV cameras zeroed in on a natural disaster or a major auto accident. The brain is like a closed circuit TV, trained on the area of known tissue damage and activity. The brain just wants to know everything that is going on around the area. The amount of pain any of us endures reflects the degree of threat our brain thinks we are under, not necessarily how much tissue damage we have sustained. Pain is a poor correlate of tissue damage, yet most people still believe the more pain you have, the more injury there must be.
What I don't like about this concept of the brain keeping tabs on an area is that a good golfer could hesitate, be tentative and unwilling to perform swings at full speed ("all out"), and eventually adopt sloppy form. This kind of game play can lead to frustration or another injury.
A good golf swing uses the left side of the body as much as the right. The hips initiate movement into the ball. The feet pushing against the ground cause a ground reaction force that sequentially travels up through the hips, the trunk and finally out the arms. The most noticeable difference between pros and amateurs is trunk rotation. Trunk rotation and flexibility are enormously important in golf. Older and less skilled players tend to use less than half the trunk rotation of younger or more skilled players.
In order to prevent injury in the first place, we need to ask ourselves, "Where do golfers become inefficient and thus injury prone?" The answer is when 1) restrictions limit the potential energy stored for elastic recoil; and/or 2) forces are dissipated improperly.
Underlying it all is posture. Proper posture ensures that the muscles of the body are optimally aligned at the proper length-tension relationships. Proper muscle balance allows for efficient functioning of force couples and joint motion. The ability of the nervous system to properly recruit all muscles in all planes of motion is called neuromuscular efficiency. Treatment to improve posture requires 1) the release of muscle tightness and trigger points in tight and overactive muscles; 2) restoring normal mobility to the neural system; 3) restoring normal ROM to the joints (especially in golfers we need to check the ankles, hips and mid-upper thoracic spine); and 4) increasing strength.
Understanding Rehab
How do we go from "I'm not able to play full out" to "I'm playing full out"? Part of the answer involves when the complete physiological process of healing is complete, along with the confidence that physical performance has been reinstated. I'm sure the brain must be satisfied that the threat levels of reinjury have subsided and thus "turned off" its closed-circuit TV surveillance. Again, the big question is, "How do we go from 'surveillance' of an injured area or an area that the brain is keeping 'tabs on' to the 'end' of rehab?"
Understanding the fascial system has helped me understand that the top sites of a golfer's pain and the site of the actual injury aren't necessarily reflective of the cause of the injury. The cause could be the consequence of inadequate motion at the foot/ankle, and/or thoracic spine, and/or hips. Learning how to stretch long fascial systems instead of isolated muscles has made an improvement in my patients' movement patterns related to golf.
Some Fundamental Corrective Exercise Strategies
Active / Dynamic Warm-Up
Bend forward at the hips to touch the fingers to the floor.
Step into a stride position, extending the right leg (lunge).
Lift the right arm, rotate the spine and the head – hold this pose for 10 seconds.
Return to the stride position. With hands on the left thigh, drop the back knee toward the floor and reach both arms overhead.
Twist the torso toward flexed front knee and hold.
Return to the hip flexor stretch position then put both hands on the floor.
Go to push-up position.
Sweep the left foot across in front – sit into the stretch and hold for 10 seconds.
Return to the push-up position.
Step forward into a forward bend and hold.
Sit into a deep squat with open knees.
Lift hands overhead, stand up and bring arms back to your side.
Now repeat this on the opposite side:
Bend forward at the hips to touch the fingers to the floor.
Step into a stride position, extending the left leg (lunge).
Lift the right arm - rotate the spine and the head – hold this pose for 10 seconds.
Return to the stride position. Hands on right thigh, drop the back knee toward the floor and reach both arms overhead.
Twist the torso toward flexed front knee and hold.
Return to the hip flexor stretch position then put both hands on the floor.
Go to push-up position.
Sweep the right foot across in front – sit into the stretch and hold for 10 seconds.
Return to the push-up position.
Step forward into a forward bend and hold.
Sit into a deep squat with open knees.
Lift hands overhead, stand up and bring arms back to your side.
I like to use rehab with bands to facilitate motion at the foot/ankle, hip and thoracic spine in order to minimize risk of golf injury. In a future article, I might go into more specific golf exercises, but for now, please get your patients started with these.
To provide patients with re-education of static alignment, especially those suffering from increased thoracic kyphosis, protracted scapulae and/or forward chin position, I have them perform a simple corrective exercise solution:
Stand, feet together, straight ahead. The feet should remain in this position for the duration of the exercise.
Put one hand beneath your clavicle and one hand on your belly button. Keeping your hands in that position, lift the chest with the hand under the collarbone while simultaneously pulling down with the belly button hand. This will help to lengthen the spine and reduce the slouched position.
Holding the achieved position, level the pelvis by raising the pubic symphysis with the lower abdominals.
Lengthen the neck by slightly tucking the chin and imagining the crown of the head is being pulled toward the sky.
Bend your knees very slightly, just enough to remove any tension from the posterior knee.
Holding the achieved position, lean forward slightly to shift the center of gravity to the midfoot instead of the heel. Practice this frequently to improve posture. This opens the chest and allows for more natural breathing as well.
Therapy Band Phasic Exercises for the Upper Body: Begin with a long (2.5 meter) band wrapped on each hand with palm open. Perform the following movements against the resistance of the band with both hands: thumb and finger abduction and extension; wrist extension; forearm supination; shoulder external rotation; shoulder abduction and extension; and scapular retraction. Repeat the movements in exactly the reverse order; then repeat the entire sequence (forward and back) 2-3 times. Maintain an upright posture with neutral neck and back throughout.
While there may be no “magic bullet” when it comes to health, this should not dissuade patients or practitioners from seeking out ingredients that offer multiple health benefits. When it comes to dietary supplements, there are thousands upon thousands of choices. So, why not choose one that can address pain and assist with mental health? A supplement that can address inflammation, while also preventing certain types of cancer.
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