I've changed the wording of the original title of this article [See part 1, "Corrrective Exercises for Golfers," in the Oct. 7 issue] to focus on "experimental" exercises, rather than corrective ones. I've been using the term corrective exercises for so long that I really bought into thinking that is what I was providing to patients. The truth is that I'm using experimental movement therapy to hopefully achieve corrections. I perform an assessment, some movement, a test or a screen, and I create a baseline (ROM, pain provocation/reduction, etc.) of information regarding the patient's status. Once I have a baseline, I experiment with exercise to see if movement therapy improves the baseline. I also practice experimenting with posture, teaching patients about body awareness, flexibility, mobility, strength, diet, nutrition, sleep hygiene and active care.
Articles on golf seem timely because I can think of at least three different organizations putting on golf seminars for chiropractors. The goal of these workshops is to position the DC as the golf performance expert and injury specialist. I don't know about you, but my mind goes to the saying, "Everything old is new!" I am certain conditioning programs can increase golf performance. Once you understand the basic known muscle activity involved in a golf swing and the leading injuries, you'll understand that a training program for golf should consist of appropriate flexibility and strengthening exercises. That brings me right back to "experimental exercise," because there is "no one size fits all" approach.
The Golf Swing
Here's some basic information you need to understand about the golf swing. Flexibility for the hip external rotators and strengthening for the hip internal rotators will address the needed internal rotation of the hips required for the backswing and follow-through. Flexibility for the hip flexors and strengthening for the hip extenders and deep stablizers of the spine will address the ability for proper weight shifting from the back leg to the front leg during the front swing, and hip extension on the lead leg during the follow-through. Flexibility for the shoulder extenders and internal rotators, and strengthening for the shoulder retractors and scapula stabilizers, will address the shoulder motion needed throughout the entire golf swing.
Some golfers need exercises because of known pathology, movement pattern dysfunctions and asymmetries. Others want exercises to get stronger, bigger, hit the ball farther or increase endurance. To accomplish the patient's goals, the first step is to create a logical approach to screening, testing or assessing them. Whatever system of analysis you use, have a checklist that gives you a baseline. Dr. Jeffrey Blanchard has created a great flexibility assessment for golfers. The Functional Movement Screen (FMS), developed by Gray Cook and Lee Burton, is another great screening tool for mobility and stability (motor control).
Step one is to perform the screen and create a movement baseline. Next, correctly identify the biggest dysfunction. Ask yourself, What is this patient's biggest issue? It could be pain relief, strength deficits, motor-control issues, core strength deficits, lack of flexibility, or even weight and/or nutritional issues. Once you focus on the biggest problem, ask yourself, What do we need to do next? For example, a weekend golfer who's running on the treadmill four times during the week with shin splints, and scores 19/21 on the Functional Movement Screen, has a performance issue. They need rest from the treadmill and a decrease in mileage. But in this article I want to focus on clients who present with shoulder pain.
Shoulder Pain
The scapula and rotator cuff are very active and are vulnerable to overuse and microtrauma in golf. In Part 1 of this article, I discussed how important proper posture is for golf. With respect to the shoulder, the glenohumeral joint can be too loose in front and too tight in back; this leads to poor muscle balance and poor shoulder mechanics.
Common shoulder injuries include rotator-cuff strains / tendinitis, bicipital tendinitis, subacromial impingement, anterior (laxity) instability, posterior capsule contracture, and scapular dysfunction. Golf swing mechanical dysfunctions that contribute to shoulder injuries include posterior capsule contracture, steep swing plane (stresses the GHJ), divots (rotator-cuff injuries), casting – excessive forces are placed in the flexors of the trail forearm. Forced external rotation on the backswing is also not friendly for the shoulder, and poor follow-through causes stress in the infraspinatus and teres minor muscles.
Rehab Plan of Action
If the patient has shoulder pain related to forward shoulders, try this strategy: 1) perform some myofascial therapy (trigger-point therapy, FAKTR, deep tissue massage, DMS, etc.) and lengthen (stretch) these muscles: levator scapula, upper trapezius, pectoralis minor / major, latissimus dorsi. 2) activate (strengthen) the mid/lower trapezius. For these muscles I often use the YTWL maneuvers (see below). For the teres minor and infraspinatus, I use side-lying external rotation exercises. 3) Integrate whole-body exercises like the squat-to-row and push-up plus exercises.
I recently had a golfer come in with right shoulder pain. His pain occurred when his arm went into the backswing and the forward swing. I recorded my static postural evaluation, performed range of motion, performed seven functional movement patterns, and used some isolated muscle testing and ortho tests. Based on this information, I came up with a working diagnosis.
Here's my interpretation of the cause of his pain. After the impact of the club on the ball during a swing, the shoulder's high-speed movement from external to internal rotation has to slow abruptly, primarily this is the job of the posterior rotator-cuff muscles (infraspinatus and teres minor) contracting eccentrically. These muscles are at a significant strength disadvantage compared to the powerful drivers into internal rotation (pectoralis major, latissimus dorsi and anterior deltoid). If the external rotators are not strong enough to deal with the eccentric demand, they start to tighten, and over time this produces a restriction to internal rotation. It is not just the muscles that become restricted; the posterior joint capsule does, too.
Experimental Exercise Program
Wing stretch: In the case of this patient, the posterior capsule needed to be stretched. For this I taught him the wing stretch. The right shoulder needed to be stretched. Place the dorsal aspect of the right hand on the outside upper gluteal region so the elbow sticks out to the side. The back of the hand touches above the patient's "pants pocket" area. Grab the right elbow with the left hand and pull it the elbow forward, simultaneously resisting the pull by stabilizing your shoulder girdle backward on the stretching shoulder. Hold this stretch for one minute.
Open book: The pectoralis muscles also needed to be stretched. For this I taught him the open book exercise. Lie on your left side with your knees bent and your arms straight out in front of you, palms together. Keeping your knees on the ground, take your top arm and rotate your upper body all the way in the opposite direction. Perform 15 reps. Repeat on the other side.
Thoracic rotation: The thoracic spine was hypomobile and needed self-mobilization. For this I taught him thoracic rotation. Get down on all fours, place your right hand behind your head, and point your right elbow out to the side. Brace your core and rotate your right shoulder (think about moving through the scapula) toward your left arm. Follow your elbow with your eyes as you reverse the movement until your right elbow points toward the ceiling. That's one repetition. Do 20 reps right and left.
Band diagonal raise: The serratus and lower trapezius was underactive. For this I taught him the band diagonal raise. Attach a band or handle to the low pulley of a cable station. Standing with your left side toward the pulley, grab the handle with your right hand in front of your left hip and bend your elbow slightly. Pull the handle up and across your body until your hand is over your head and your thumb is pointing up (a Statue of Liberty pose). Return to the starting position. Complete 10-15 reps and repeat with your left arm.
These types of PNF diagonal patterns are the first and foremost band "bang for the buck" exercise for me. They are particularly effective when training for sports that have an overhead throwing, hitting and swinging component (e.g., tennis). High-repetition PNF patterns is the best thing for strengthening the shoulders connective tissues and musculature.
Scaption Exercise: This is the plane of motion the scapula moves in. The motion is important because it helps the shoulder joint achieve healthy mechanics. The scaption exercise primarily works the supraspinatus muscle. Have the patient perform this exercise standing in front of a mirror to monitor their form. Hang the arms down by the thighs and supinate both hands to a thumbs-up position. Retract and depress the scapulas as they lift the arms up to shoulder-height at a 45-degree angle from the trunk. The arms should make a Y in front of them. Make sure that the upper trapezius isn't pulling the shoulders into the ears. If it is, the patient should work on pulling the shoulders down in order to push the arms up. Perform two sets of 15 reps per set.
Y-T-W-L exercises:: Most of the shoulder routines I put patients on also include the lying Ys, Ts, Ws and Ls (Y-T-W-L). These maneuvers drastically improve the function of the shoulder (without bands). Have the patient lie prone on a bench with their upper shoulders off the bench to perform these exercises, which involve raising the arms / shoulders to mimic the shape of a Y, T, W and L (e.g., arms up over the head forms a Y; arms straight out to the sides forms a T). Standing Y-T-W-L exercises can also be performed using a stretch strap, which allows the patient to maintain a consistent arm position.
So, in this practice of experimental exercises, I always ask myself, "Why do some people excel and get better while others fail to perform well? I don't always know, but I have the courage to keep trying new exercises because of a loving commitment to helping others. That's what experimental exercises are all about. Try them with your golfer patients and see what results you can achieve
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