Running Head: GOLF PERFORMANCE AND INJURY PREVENTION 1. Golf Specific Physical Therapy for Performance and Injury Prevention.

Transcription

1 Running Head: GOLF PERFORMANCE AND INJURY PREVENTION 1 Golf Specific Physical Therapy for Performance and Injury Prevention A Case Report Presented to The Faculty of the College of Health Professions and Social Work Florida Gulf Coast University In Partial Fulfillment of the Requirement for the Degree of Doctor of Physical Therapy By Daniel M. Esperon May 2014

2 GOLF PERFORMANCE AND INJURY PREVENTION 2 APPROVAL SHEET This case report is submitted in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy Daniel M. Esperon Approved: Stephen A. Black, DS.c, MeD, PT, ATC/L, NSCA-CPT Committee Chair Thomas Bevins, MS, PT Committee Member The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline.

3 GOLF PERFORMANCE AND INJURY PREVENTION 3 Acknowledgements Apart from the efforts of myself, the success of any experience depends largely on the encouragement and guidance of many others. I take this opportunity to express my gratitude to the people who have been instrumental in the successful completion of this case report. Above all I would like to thank my wife Elaina for her personal support throughout this program. I would also like to thank my son Mason for he is truly a blessing and has shown me the true meaning of happiness in life. I would like to thank my parents for their unequivocal support throughout, as always, for which a mere expression of thanks likewise does not suffice. I would like to thank a supportive and highly knowledgeable committee, Dr. Stephen Black and Professor Thomas Bevins, who provided me with the necessary insight and feedback required to complete this paper to the best of my abilities. I would like to thank everyone involved in the completion and production of my scholarly website and paper. This includes assistance with videography, photography and exercise intervention recommendations. Lastly, I would like to thank all of the faculty members in the Doctor of Physical Therapy program at Florida Gulf Coast University for their continued support and guidance throughout this program. Your efforts have paved the way for a successful career as a Physical Therapist.

4 GOLF PERFORMANCE AND INJURY PREVENTION 4 Table of Contents Abstract...5 Background...6 Purpose...7 Biomechanics...7 Performance...11 Injury Prevention...15 Stability Segments...18 Method...20 Case Study Background...20 Patient Introduction...22 Golf Specific Evaluation...24 Summary of Findings...25 Recommendations...26 TPI Screen...27 Golf Program...32 Results...33 Subjective...33 Golf Specific Evaluation...34 Discussion...35 Summary of Findings...35 References...37 Appendix: Periodized Golf Fitness Program...40

5 GOLF PERFORMANCE AND INJURY PREVENTION 5 Abstract The purpose of this case study is to discuss and establish evidence to support and further the field of golf fitness and physical therapy. The ultimate goal for a golfer is to achieve proper speed, accuracy and consistency by bringing a large number of segments into action in the correct sequence. Physical limitations in the areas of mobility, flexibility, stability and strength can limit the ability of the golfer to execute a biomechanically efficient golf swing. Most of the game s best athletes are currently redefining golf to include not only golf professionals, but health professionals as well. Case patient is a 62 year old male who has been playing golf for 20 years. Prior to initiating programming, the patient's chief complaint was bilateral hip pain and muscular restriction feeling when performing physical activity. The patient experienced intermittent pain in bilateral hips which was exacerbated with axial loading and during rotational movements in standing. A 20-week periodized program designed to fulfill all necessary aspects of golf specific strength and conditioning was used. Flexibility and strengthening were highlighted in this program. Lower body stability accomplished through hip balance and strengthening exercises coupled with tissue extensibility techniques were used in the program. By week 10, the patient was able to complete a full round of golf with minimal to no pain in bilateral hips.

6 GOLF PERFORMANCE AND INJURY PREVENTION 6 Golf Specific Physical Therapy for Performance and Injury Prevention Background The sport of golf and one s perception of the game has drastically evolved over the course of the past decade. Evidence based advancements in clinical theory and practice have altered the way both average and professional golfers go about approaching the game. There has been a revolution in the way of performance and injury prevention in relation to the game itself. Combined with advancements in club and manufacturer research, golf has become a sport known for its competition. Current research demonstrates substantial evidence that a golf physical training program can supply advancements in both power and consistency to all levels of play. However, the growing market of golf fitness is saturated by non-evidence based research and club manufacturers seeking to gain financial benefit. Unfortunately, many golfers are not being provided with the correct knowledge on methods of applying learned golf training skills to current strength training programs. Since this is the case, time spent on useless golf specific exercise generates a less than ideal result for the golfer both in the way of performance and injury prevention. The golf swing is an intricate series of muscular firing and inhibition sequences which has long been studied and appreciated by biomechanists. However, golf professionals are just beginning to understand the physical attributes related to the golf swing and how to apply this to training programs and lessons. Both instructors and players have come to the realization that there is a need for adequate strength, flexibility, and balance training programs in the sport of golf. These programs aim to alter swing mechanics and correct limitations in order to enhance golf performance abilities and potentially prevent injuries (Farrally et al., 2003).

7 GOLF PERFORMANCE AND INJURY PREVENTION 7 Purpose Golf has grown in popularity with time, and is no longer considered to be the sport of a single generation. Recent literature does suggest that conditioning for injury prevention is applicable to the entire population of golfers, but it is especially important for both junior golfers during development and senior golfers for overcoming injuries (Lephart, Smoliga, Myers, Sell & Tsai, 2007). By applying the principle of specificity to individualized strength training routines, the golf fitness population will be able to correct and promote changes in physical characteristics. These changes will influence joint protection and enhance performance capabilities for athletes of all ages. The purpose of this case study is to provide golf fitness instructors and health professionals with evidence based information regarding golf performance and injury prevention. Biomechanics Golf biomechanics applies the principles and techniques of mechanics to the structure and function of the golfer in an effort to alter and advance golf technique and performance (Hume et al. 2005). Biomechanics can be defined as the study of the mechanics of a living body, especially of the forces exerted by muscles and gravity on the skeletal structure. In maximum rotational velocity sports such as golf, it is necessary to create maximum speed of a distal body segment. In this case, the distal body segment is the club face of the golf club itself. While evaluating the biomechanics of the sport, it is generally recognized that there is a structurally timed sequence of body segment motions associated with the proper swing. This sequence has been termed the kinematic sequence. By using qualitative and quantitative biomechanical analyses tools, biomechanists have been able to define the movement patterns of golfer's swings

8 GOLF PERFORMANCE AND INJURY PREVENTION 8 as well as the resultant joint torques and patterns of muscle activity that produce these movements (Hume et al 2005). The kinematic sequence of the golf swing should be examined from the ground up. It is necessary to establish the primary foundation which is the pelvic shift rotational movement component. This is the component which allows the golfer to utilize ground reaction forces in order to produce maximum rotational velocity in the pelvis. Following the pelvis, the upper body will rotate around the pelvic base. In some cases, the pelvis is not stabilized and an unstable base is recognized. This instability can be corrected with the use of core stabilization exercise for the thoraco-lumbar region. The resistive force established, when properly sequenced will produce upper body rotation via transmission from the core musculature. However, most of the rotational force will be derived from the active muscle contraction of the glute and abdominal muscle groups. The motion produced will be referred to as the pivot or rotational action. This action is essentially going to be the swing power producer. The full golf swing consists of three major phases. These phases include: the backswing, the downswing and the follow through. With the backswing, there is an emphasis placed on the proper lateral shift of body weight to the trail leg and the power coiling development from distal to proximal. The backswing is going to set up the golfer in a leveraged position to develop an accurate and properly sequenced downswing which will serve as the base for the power output through the kinematic chain. The average duration of the backswing for elite players during a golf drive has been found to be <1 second (0.82 seconds) (Cochran & Stobbs). In the backswing, the shoulders, hands and club head must start and end in the same sequence. The shoulders will rotate with the hips and the shift in weight will increase the range of hip rotation of the trail leg. During the backswing, the left arm is pulled back across the upper chest (right handed golfer),

9 GOLF PERFORMANCE AND INJURY PREVENTION 9 and it is pressed against the upper torso by the end of the backswing. The left upper extremity is inert in the golf swing and it responds relatively passively to movements of the upper torso during the downswing. When the hands reach the top of the backswing, the right shoulder will be coiled in an abducted and externally rotated position. These specific positions will provide a directional influence on the shaft of the club moving along the swing plane. Most players backswing motion results from shoulder and pelvis rotation around a stable base of support rather than from lateral weight shift, which is thought to enhance club-head speed with force transmitted from the large muscles in the buttocks, hips and legs (Hume et al 2005). If the energy of the hips, shoulders and arms release in the proper sequence, a correct kinematic chain reaction will result in maximum rotational velocity in the downswing. This area is a focus for training, as without the correct preparation and loading to get to the end point, consistency and power will be greatly compromised. The backswing is characterized by a rotation of the shoulder complex to the trail side, anatomically resulting in scapular retraction and opposing scapular protraction as the scapula move around the trunk. This results in the trapezius muscle group and the opposing subscapularis being the most active muscles in the upper body, with the rhomboids also active. (Kao et al 1995). The pelvic muscles provide a stable base for the trunk to rotate, while lumbo-pelvic movement results from abdominal and gluteal group activation as the body weight transfers to the lead leg. The downswing is the phase in which a golfer will return the club head to the ball in the correct swing plane with the potential for maximum rotational velocity. This phase quickly returns the club back to the ball, with trunk and hip rotation and a transfer of weight from the

10 GOLF PERFORMANCE AND INJURY PREVENTION 10 trailing leg to the lead leg, resulting in gluteal and abdominal activation. At this point in the swing, the hips quickly rotate and develop a summation of forces with the upper body. In the downswing, the left arm externally rotates (right handed golfer) and moves toward the midline from the horizontally adducted position (the subscapularis and latissimus dorsi are very active in the forward swing phase with the pectoralis major becoming more active in the acceleration phase) (Jobe, Moynes &Antonelli 1986). Muscle activity during this segment is high in the pectoralis major in order to initiate internal shoulder rotation and flexion, while the upper serratus anterior contracts to assist scapular protraction. The acceleration phase generates a substantial amount of activity in the left pectoralis major to control left arm abduction and external rotation eccentrically. As the golfer rotates from the trail leg to the lead leg, the gluteal and the abdominal muscles on one side of the body act to maintain body posture with both muscle groups becoming active on the opposing side of the body later during the acceleration phase (Pink, Perry& Jobe 1993).With the downswing, the proper kinematic sequencing needs to be applied. The kinetic chain action involves the initiation and recruitment of the pelvis followed by movement of the torso and arms and lastly out through the club face. If this sequence is achieved, the particular swing can be repeatable and efficient which will provide consistency, accuracy and most of all power. The purpose of the follow-through is to decelerate the body and club head by using eccentric muscle contraction (Pink, Perry& Jobe 1993). At this point, the upper body will lag behind the pelvis after impact, and results in the spine producing an extension moment, better known as the reverse C. The head of the golfer which has remained stationary throughout the swing is now in the process of lifting up due to the trunk rotation and momentum of the swing itself. The hands and wrists follow the plane of the swing path. The left shoulder and arm abduct

11 GOLF PERFORMANCE AND INJURY PREVENTION 11 and externally rotate, and the right shoulder and arm adduct and internally rotate (right handed golfer). When the hands reach shoulder height both elbows flex to decelerate the speed of the arms and the trunk rotation whilst maintaining postural stability (Hume et al. 2005). Rotator cuff activity is also high to control the arm movement in this follow through phase. Injuries to the lower back tend to occur in this phase of the golf swing. For amateur golfers, one of the issues commonly dealt with is the lack of acceleration through impact. This can be detrimental to the swing and shot itself because proper acceleration not only increases accuracy, but it also decreases the possibility of injury. Performance Watanabe, Satio & Hokari (1998) biomechanically analyzed swings of 22 amateur golfers and reported that skilled players with lower golf scores had higher club head velocity, higher ball launch angle, lower standard deviation of ball velocity, and faster body-twist angular velocity. These are skills that can be improved with strength training techniques and flexibility programs designed individually for golfers. In order to execute each phase of the golf swing efficiently, the neuromuscular system must maintain certain levels of strength. This allows the golfer to maintain a fixed spine angle, execute the postural position required in the swing, and generate speed. Basically, a loss of strength equates to the loss in stabilization during the golf swing affecting every phase of the swing from the top of the backswing to the end-follow through. The physical demands in golf are not yet well understood, even though growing attention is being paid to increasing muscle strength and flexibility to optimize overall performance. Evidence based research concerning golf specific training to improve golf performance is limited, yet on the rise. Most of the evidence regarding the biomechanics of a golf swing is

12 GOLF PERFORMANCE AND INJURY PREVENTION 12 completed by golf equipment manufacturers looking to market their product to the public (Farrally et al., 2003). However, in a study conducted by Thompson, Cobb & Blackwell (2007) a functional training program resulted in significant improvements in club head speed and several components of functional fitness for golfers. Smith, Callister & Lubans (2011) suggest that strength and conditioning programs can have a positive effect on the golf swing and fitness characteristics of golfers. In a study conducted by Lephart et al., (2007) all ROM variables showed significant improvement following a conditioning program, which is attributable to the program specifically targeting golf specific musculature. These are just a few of the research articles to be discussed that will support the theory that golf specific strength and conditioning can improve a golfer s performance. Research suggests that strength gains are both velocity and movement specific. What this means is that the largest training effects (increases in force development) occur during tasks which are most similar to the movement and velocity that an athlete performed while training (Behm & Sale, 1993). In theory, this is indicating that golf specific training should imitate the actual golf swing to some extent in order to comply with the principle of specificity. Contributing muscle groups should be recruited, similar characteristics should be implemented and the rate of contraction for specific musculature should correspond to matching swing phases. Ronda, Medina & Badillo (2011) indicate a relationship between muscle strength and driving distance, swing speed and/or ball speed. In a study conducted by Lephart et al., (2007) a golf-specific training program successfully improved a majority of physical characteristics in recreational golfers as hypothesized. Increases in strength resulted from improved neuromuscular function; such improvements are important for optimizing golf performance, because they may increase the power of the swing without increasing muscle mass. Golfers have to be aware of this

13 GOLF PERFORMANCE AND INJURY PREVENTION 13 because they do not want to train for increased muscle mass. This could lead to excess muscle hypertrophy that could have a direct impact on flexibility and hinder overall performance. During the golf swing, the muscles of your body, in conjunction with the swinging motion, generate power. In order to increase the power outputs of your muscles, it is necessary to implement specialized exercises. The implementation of these types of exercises in to a training program over time will increase the power output of your muscles. To generate these high speeds, muscular power must be generated at a high velocity with little resistance to be overcome (Lehman 2006). However, as when beginning any other strength training program, a baseline strength level should be established before any golfer can begin to train for increased swing power and performance. According to Lehman (2006), a golf specific strength training program is designed with the intention to replicate the specific movement characteristics of a well sequenced golf swing; therefore, greater strength and power gains will be transferred to the swing when compared with traditional strength exercises. Previous golf training studies have used changes in club head speed as the measurement of performance when determining the effect of a strength training program. In a study conducted by Lephart et al., (2007) their training program resulted in a 5.2% improvement in calculated club head velocity, which is consistent with other reported values. According to Wells, Elmi & Thomas (2009), given the body of research demonstrating the positive effect of physical training on many different sport activities, it can be hypothesized that there would be positive correlations between physiological performance measures and golf performance measures. According to Ronda et al., (2011) further studies should determine muscle strength needs in relation to final swing performance, using well designed experiments and strict isoinertial assessment protocols which adequately relate to specific golf motions, age and skill level. As of

14 GOLF PERFORMANCE AND INJURY PREVENTION 14 today, recent literature has shown that improvements in strength, in conjunction with flexibility and balance lead to an increase in ball speed, carry distance and total distance (Ronda et al., 2011). This is due not only to the increased strength, but also to the increased postural control that could assist in maintaining balance throughout the entire swing process. In order to execute every phase of the golf swing efficiently and effectively, a certain level of postural strength is required. This allows your body to correctly sequence the muscular contractions required of the swing, maintain your spine angle, and generate power. Exercise selection for the golf specific program is supported by the exercise s relevance in achieving specific muscular activation, minimization of excessive or asymmetrical spinal loading or theorized sub-optimal muscular recruitment (i.e. high levels of upper trapezius recruitment during exercises designed to train serratus anterior) and the expert opinion of leading researchers Lehman (2006). In a study supplied by Lephart et al., (2007) general flexibility and strength exercises were utilized for 8 weeks and resulted in a 3-6% increase in club head speed. Using more vigorous strength exercises, plyometric training, and medicine ball exercises, there were increases in club head speed of 1.6 and 1.5%, respectively, as well as a 4.3% increase in driving distance. With these results, it is easy to see that the combination of several training techniques could be used as a supplemental tool into any golf specific training program. According to Ronda et al., (2011), there is a positive correlation between skill (handicap or golf score) and muscle strength, especially grip strength. This relationship seems to be observed in adult golfers as well as in junior players. As golf continues to evolve as a whole, new ideas and theories continue to be implemented. Training for golf has progressed from the initial concept of sagittal plane orientation towards an emphasis on unilateral training and multi-planar training. A lot of this has

15 GOLF PERFORMANCE AND INJURY PREVENTION 15 to deal with the competition factor in the game and players wanting to increase their performance in order to obtain the advantage. Injury Prevention Golf is currently a sport in which physical training is just starting to gain recognition as an integral component of elite players' practice regimen contributing to the ability to play at a high level consistently and without injury (Mchardy, Pollard & Luo, 2007). Despite being a lowimpact sport, 60% of professional and 40% of amateur golfers suffer from injury each season. One explanation for this high rate includes the repetitive bending and twisting of the swing. However, it is suspected that most golfers do not participate in any form of offseason training for their sport, nor do they warm up before exercise. This is especially important in the large number of retirees who have the time and resources to play golf (Brandon & Pearce, 2009). While many golf injury studies describe the associated mechanisms and types of injuries, less attention has been given to research relating to the various injury prevention measures for this sport (Sherman & Finch, 2000). Their needs to be more of a formal evaluation of the necessary programming associated with the prevention of injuries. Particular attention should be given to evaluation of the golf swing and its relationship to specific injuries such as low-back, wrist, and shoulder problems. According to Brandon & Pearce (2009), a basic review of golf swing biomechanics reveals significant torque stress on the shoulders, elbows, wrists, and low back. The erector spinae and abdominal muscles play a vital role and are utilized throughout the entire golf swing. It is not surprising therefore that the majority of golf injuries occur at the location of these 2 large muscle groups (Reed, 2005). Many golfers limit their muscle strengthening and endurance to a

16 GOLF PERFORMANCE AND INJURY PREVENTION 16 few muscle groups in their exercise regimen, when in fact; many muscle groups should be included in a sound strengthening program. These muscle groups include the abdominals, lower back extensors, hip flexors and extensors, hip adductors and abductors, and the muscles of the anterior and posterior upper extremities. These muscle groups should be exercised on a consistent schedule to prevent possible injury associated with the golf swing. The golf swing generates an incredible amount of force. Axial twisting alone has been identified as a risk factor for low back disorders. If a golfer is lacking in any of the physical requirements of the golf swing, compensations in the execution of the swing result and this makes the athlete susceptible to injury. These compensations lead not only to performance faults such as a loss of club head speed but also to injuries that could have been prevented through strengthening. In order to execute the golf swing correctly, an individual has to transfer power and strength from the legs up through the body and out through the club. To accomplish this task one needs to have tight control of the trunk muscles to protect the back during the phases of the golf swing, which includes; the back swing, the downswing, impact, and the follow-through (Reed, 2005). A golf injury prevention program should also focus on developing muscle endurance and motor control to provide muscular stability for the lumbar and shoulder regions (Lehman 2006). There is a lack of research that compromises clear evidence and evaluates the efficacy of golf specific exercise programs in preventing injuries. However, from the research gathered, it is clear to see that golf specific exercise programs do in fact have a direct impact on overall injury prevention. According to Farrally et al., 2003, conditioning programs are highly recommended for all older players irrespective of their level of participation. Not only could the programs prevent injury, they also have the potential to improve performance. Such programs should

17 GOLF PERFORMANCE AND INJURY PREVENTION 17 incorporate flexibility, strength, endurance, speed and balance exercises specifically tailored to the demands of golf. This is the common theory behind all of the current golf literature. Postural control muscles are extremely beneficial for preventing injuries in the game of golf, and proper posture is essential for golf performance. Without proper posture a golfer could not complete the necessary motions in the correct plane consistently to keep the club on the proper path while preventing injuries caused by repetitive stress. Golfers tend to develop imbalances, which impair performance and increase injury risk. A solid golf-specific conditioning program must look for these postural imbalances (Lephart et al., 2007). When assessing postural control deficits, both static and dynamic balance should be evaluated. Static posture is an attempt to maintain postural control while limbs and center of gravity remain constant and is important as the golfer addresses the ball at the start of every swing. The proper address posture should be utilized and reinforced during all golf-specific exercises. Once sufficient static posture is achieved, dynamic balance is then evaluated. Dynamic postural control is important to every aspect of our activities of daily living. Since postural control is at the center of all movement it is also the center of an athletes performance. Dynamic stability will allow the golfer to move efficiently through the swing motion keeping the club on its proper path. This will increase consistency and help to maintain joint & soft tissue integrity throughout the lifetime. For all dynamic movements, the complex interaction of many body systems including the connective tissue, musculoskeletal and neuromuscular systems must be working in unison to complete tasks without injury and with coordination. All these systems act simultaneously at a particular joint to stabilize it. The body and brain must coordinate and activate these systems to minimize stress and maintain integrity of the joints during movement. If these systems are not

18 GOLF PERFORMANCE AND INJURY PREVENTION 18 working together or if there is a system not functioning up to its full potential, the risk of injury increases. According to Reed (2005), with more than 21 million recreational golfers of all ages and fitness levels playing golf, the chances of golfers developing lower back pain if they are not in sound physical condition will increase. Unfortunately, many golfers continue to play without a proper warm-up, and are in poor physical condition, increasing their risk for injury. When designing a golf specific program, several training characteristics need to be covered for performance and injury prevention. These characteristics include; mobility/flexibility, strength/stability, power, and neuromuscular efficiency development. By targeting golf-specific physical limitations, golfers can develop a more stable base with greater functional flexibility. Thus, golfers who engage in a golf-specific training program may be able to limit age-related changes and thereby maintain greater overall health while improving their golf game (Lephart et al., 2007). Stability Segments In order to develop stability of the lower body, it is imperative that the health professional and golf professional establish unrestricted motion in the ankle, knees and hips. Utilizing the kinematic sequence will provide the health professional with means of developing a comprehensive biomechanical and physical evaluation. During the golf swing, golfers force their bodies into maintaining balance on a stable pelvic base. This can be difficult to do with unbalanced segments above or below the pelvis. Golfers who are unable to maintain position will likely over rotate or use strategies such as hyperextending a knee in order to develop rigidity and maintain posture.

19 GOLF PERFORMANCE AND INJURY PREVENTION 19 It is important to think about the different systems involved and develop proprioceptive, strengthening, neuromuscular and flexibility routines for the lower body. Beginning with closed chain exercises will provide golfers with familiarity into activities of daily living and is important for less experienced athletes and those who are less active. Closed chain exercises are of great importance because they correlate with the golf swing. During the swing you maintain foot position while controlling posture and stability. This allows movement of the body or trunk on a fixed upper or lower extremity. Having proper stability of the upper body will ensure proper motion in the biomechanical properties of the swing itself. The shoulder complex is of great importance considering the fact that it is such a vulnerable and complex joint. For golf, each individual needs to be able to control and stabilize scapular positioning from start to finish. This can be achieved by developing strength in the scapular stabilizers and promoting the proper dynamic stability of the muscle teams (lower trapezius and the rhomboids). Specifically those muscles that hold and pull the scapulas inward and downward are of great importance. The main muscle group responsible for the generation of power is the core musculature. This thoracolumbar and abdominal area form the core loop which helps provide the stability throughout each phase of the swing. Increasing the activation capabilities of this muscular group can increase one s ability to protect their spine and have direct performance enhancement applications. The necessary contributors to be worked on in this region are the transverse abdominus, internal and external obliques and rectus abdominus anteriorly while posteriorly the quadratus lumborum and multifidi are of great importance with stabilization.

20 GOLF PERFORMANCE AND INJURY PREVENTION 20 The golf swing is a very complex series of movements that involves the movement of the upper body around a stable pelvic base. The ultimate goal for a golfer is to achieve proper speed, accuracy and consistency by bringing a large number of segments into action in the correct sequence. Physical limitations in the areas of mobility, flexibility, stability, strength, and power can limit the ability of the golfer to execute a biomechanically efficient golf swing. Power is dependent on two things; mobility and strength. This is what the basis of a golf specific training program should be focused around for performance benefits and injury prevention. Method Case Study Background Physical conditioning has become a major part of today's player development. The purpose of this case study is to discuss and establish evidence to support and further the field of golf fitness and physical therapy. Most of the game s best athletes have been and are currently redefining golf to include not only golf professionals, but health professionals as well. An integrated approach is needed to address both physical and mental limitations which are presented with each golfer. An individualized approach to treatment is determined by a diverse team of professionals who use their skill sets to develop evidence based programming. Performance integration into the game of golf requires the health professional to evaluate the results of a detailed examination in order to provide the necessary strengthening, flexibility and various other treatment approaches to their athlete. Flexibility is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain free range of motion. Muscle length in conjunction with joint integrity and the extensibility of periarticular soft tissues determine flexibility (APTA: Guide to

21 GOLF PERFORMANCE AND INJURY PREVENTION 21 PT Practice, 2001). As it relates to golf specific strength and conditioning, the most commonly misunderstood programming is the flexibility program. When a golfer who is "tight" begins a weight training program, they are beginning the program with a faulty base. What the golfer is doing is strengthening a dysfunctional joint structure. Flexibility is related to the extensibility of musculotendinous units that cross a joint. When you strength train and do not stretch, your muscles shorten and begin to lose their range of motion. In golf, a muscle that doesn't have proper range of motion cannot be considered a normally functioning muscle at all due to its inability to contribute normal motion to the swing. A muscle that can't move is a dysfunctional muscle no matter how strong the golfer is. That doesn't mean don't focus on weight training. Weak muscles do not provide a significant amount of benefit either. Neither weak muscles nor tight muscles are going to allow the golfer to produce the proper kinematic sequence associated with the demands of the golf swing. Research suggests that strength gains are both velocity and movement specific, meaning that the largest training effects (increases in force development) occur during tasks which are most similar to the movement and velocity that an athlete performed while training (Behm & Sale, 1993). In theory, this is indicating that golf specific training should imitate the actual golf swing to some extent in order to comply with the principle of specificity. Contributing muscle groups should be recruited, similar kinematics should be implemented and the rate of contraction for specific musculature should correspond to matching kinematic sequence. Screenings and evaluations are major parts of any physical therapy program. The conclusion one develops when screening a number of golfers is that no two golfers are exactly the same. A physical therapist may find it convenient to assess using key clusters, but it is important to think outside the box and analyze based on findings and not based on assumptions.

22 GOLF PERFORMANCE AND INJURY PREVENTION 22 Each test can be modified to fit individual needs and correlate to anticipated programing. Then it is important to use the information provided to develop treatment approaches for golfers. Physical therapists may work with fitness professionals, golf professionals and medical professionals to develop the necessary treatments for each golfer. Therapists are not there to evaluate golf swings; however, they are there to develop interventions for area specific physical limitations which could be preventing the necessary biomechanical association between the club and the golfer. With the appropriate training, Physical Therapists possess the knowledge it takes to implement an individualized golf therapy program into their patient's treatment sessions. Most recreational golfers have some type of physical limitation that causes them to have mechanical breakdowns in their golf swing. Whether it is a lack of flexibility, insufficient strength, or physical pain, these impairments can limit the player s ability to swing with optimal efficiency. Lately, the paradigm has shifted towards improving the physicality of the golfer. Tiger Woods raised the popularity of implementing golf performance based exercise programs designed to improve swing speed, power, balance, and accuracy. Now almost every professional golfer on tour has their own team of professionals including golf performance trainers and physical therapists to give their body an edge on improving their performance on the course. Patient Introduction Name: Patient will be referred to as Mr. Smith for confidentiality purposes Age: 62 Sex: Male Handicap: 15 Height: /2

23 GOLF PERFORMANCE AND INJURY PREVENTION 23 Weight: 178 DOB: 10/01/1950 Years Playing Golf: 20 Right or Left Handed: R Plays Golf: R Current Exercise Routine: 3-5 sessions/week (Cardiovascular (30 minute average per session) and strength training (free weights and selectorized equipment combination)). No written exercise programming. Highlights of Current Program: Cardiovascular exercise for weight management and core strengthening. No major surgeries: two inguinal hernia repairs; spinal stenosis; osteoarthritis of spine; osteoarthritis of bilateral hips (Patient has granted author permission for health history to be utilized in the case report) Prior to initiating programming, Mr. Smith s chief complaint was bilateral hip pain and muscular stiffness feeling when performing physical activity. Mr. Smith generally experienced constant pain in bilateral hips which was exacerbated with axial loading and during rotational movements in standing position. Pain contributed to decreased ability to golf as much as patient would like. One round of golf would be cut short on occasion secondary to the fact that pain in the hips and spine was inhibiting his ability to swing the golf club. Mr. Smith had never received any professional exercise programming or instruction prior to beginning this program. He has never received physical therapy intervention for his spine and bilateral hip osteoarthritis. Mr. Smith describes his pain as being day-to-day with pain level. On average pain can range from 4-6/10 with pain upon waking up being the worst. Functional mobility has decreased

24 GOLF PERFORMANCE AND INJURY PREVENTION 24 secondary to pain and muscular restrictions. Mr. Smith does exercise 3-5 x/week; however, programming is not written nor does it address functional limitations and biomechanical inefficiencies related to his current physical status. Mr. Smith s goal is to decrease pain to 2-3/10 by 6 weeks and be able to complete a round of golf with minimal to no pain in 12 weeks. Golf Specific Evaluation Patient presents with increased thoracic kyphosis with forward head posture. Mr. Smith presents with forward flexed trunk posturing during static standing contributing to one type of lower crossed syndrome. Right shoulder depression and right hip slightly lower than left. Mr. Smith demonstrates increased bilateral subtalar pronation while standing and pes planus. Decreased knee extension and maintains slight bilateral knee flexion in standing. His current exercise routine is strength training dominant and flexibility is limited. This is apparent in postural evaluation. Forward shoulder position and decreased mobility alters ability to perform full range of the following functional movements: overhead reaching, turning head left and right, reaching behind back. Patient presents with bilateral hip external rotation tightness and hip flexor tightness. Upper crossed syndrome with shortened upper trapezius, levator scapulae, suboccipitals, sternocleidomastoid, pectoralis major and minor. Lack of thoracic spine extension is limiting backward bend or arching of the lower back. T-spine mobility restriction noted leading to loss of spinal rotation and inhibiting necessary backswing. Right compared to left hip adductor tightness. Right ASLR limited compared to left. Patient s inconsistency with flexibility programming in current routine is apparent with mobility/flexibility screening. Patient demonstrates compromised mechanics secondary to bilateral hip pain (OA) resulting in shortened and inhibited hip complex musculature.

25 GOLF PERFORMANCE AND INJURY PREVENTION 25 Tightness/fascial restrictions of the latissimus dorsi, erector spinae, multifidus, deep spinal rotators, quadratus lumborum reduces Mr. Smith s ability to disassociate the lower body from the upper body during the golf swing is noted. Limited thorax to pelvis separation is correlated to reduced spinal mobility and shortened latissimus dorsi flexibility. Right hip internal rotation is limited contributing to sway and is necessary for full rotation into the right hip. Since Mr. Smith s body is unable to rotate around the right hip due to joint and/or muscular restrictions, lateral movement is dominating the pattern. Soft tissue restriction also noted into right groin and bilateral ITB and vastus lateralis musculature. Summary of Findings C-shaped postural presentation with mobility restrictions noted into anterior, medial, lateral and posterior hip complex Soft tissue restrictions as result of upper crossed syndrome upper quadrant and cervicalthoracic region Mobility restrictions bilateral hip complex Muscle imbalances which include weakness in abdominals and lower kinetic chain resulting in decreased stability and compromise of mobility in surrounding joints Pain secondary to OA in bilateral hips results in movement limitations and bilateral soft tissue restrictions. Patient is unable to complete and move through full range.

26 GOLF PERFORMANCE AND INJURY PREVENTION 26 Recommendations Address flexibility and mobility concerns associated with decreased hip mobility and upper crossed syndrome Initiate programming to include corrective exercise and active isolated flexibility programming Initiate prehabilitative exercises to address concerns associated with cervical tightness, hip immobility and decreased thoracic mobility Educate patient on proper exercise technique and importance of flexibility programming

27 GOLF PERFORMANCE AND INJURY PREVENTION 27 TPI Screen Pelvic Tilt Test: Starting pelvic tilt- C-posture Limited motion (arching/flattening); shake and bake movement quality Pelvic Rotation Test: Limited mobility bilateral, lateral motion Torso Rotation Test: Limited mobility bilateral Overhead Deep Squat Test: Arms crossed limited with right dorsiflexion limited Toe Touch Test: Limited toe touch bilateral 3 90/90 Test: Right Standing: Equal to spine angle loses motion in golf posture Left Standing: Equal to spine angle loses motion in golf posture Wrist Four Ways Test: WNL Single Leg Balance Test: 0-5 seconds bilateral Lat test: covers the nose bilateral Cervical Rotation Test: limited bilateral Seated Trunk Test: < 45 degrees bilateral Half-Kneeling Rotation Test: bilateral bar behind back equal to bar in front Thomas Test: tight bilateral (quadriceps and hip flexor) Reach Roll and Lift Test: WNL Hip Abduction Test: Glute medius inhibited bilateral Leg Lowering Test: Pressure drops with core activation Bridge with Leg Extension Test: Glutes weak bilateral Active Straight Leg Raise Test: 54 degrees right, 56 degrees left Hip Rotation Test: 35 int. and 42 ext. right, 36 int. and 48 ext. left

28 GOLF PERFORMANCE AND INJURY PREVENTION 28 It is apparent that Mr. Smith has developed tendencies in his golf swing and physical activity lifestyle which have limited his golf performance capabilities. Flexibility and muscle imbalances are detrimental to an average golfer s swing and more specifically to consistency and power. Mr. Smith has developed a C-Spine swing fault and tight musculature in bilateral lower extremities which causes him to compensate with upper body rotation. This compensation results in a loss of posture and early extension. Loss of stability and mobility is noted throughout kinetic chain and the inability to properly separate upper body from a fixed pelvic base is demonstrated. Lack of mobility causes Mr. Smith to swing out of sequence and the timing of the golf swing is compromised. By establishing a long backswing with decreased torso rotation, Mr. Smith must compensate and force the club into the proper swing path before impact. This not only causes excessive force up the kinetic chain, but also causes inconsistencies with the golf swing itself (as well as proper contact). Mr. Smith lacks core strength and stability. Lateral slide and sway causes excess hip pain during the golf swing and inhibits ability to generate force production. Strength in the lower and upper bilateral extremities is not of concern secondary to muscular strengthening exercises currently on programming. However, muscular tightness has been accumulated as a result of the lack of supplemental flexibility exercises in current daily routine. With the ability to stabilize the pelvic base and co-contract necessary musculature, Mr. Smith will be able to generate and produce the proper swing components allowing for improved force production and consistency. Failed seated trunk rotation test which was worse on the trail leg indicates decreased ability to perform necessary follow through without excess lateral slide. By creating a forced velocity unilaterally, Mr. Smith is allowing his body to develop an imbalance of trail and lead leg musculature. By having this imbalance, Mr. Smith is making his body more susceptible to injury

29 GOLF PERFORMANCE AND INJURY PREVENTION 29 by potentially overstressing the stronger side and not being able to transfer the force to the lead leg (hanging back/slide/sway). Mr. Smith s training age is significant enough to incorporate advanced level resistance training exercise into his periodized golf specific routine. It should be noted that this program has been individualized and may not reflect generalized golf strength and conditioning needs. As with any sport program, the principle of specificity is utilized in order to assist with golf specific movement processes. The goal of this program is to provide Mr. Smith with the necessary prehabilitation exercises and resistance training exercises in order to correct and limit swing fault potential which has been impacting biomechanical insufficiency and decreasing force production.

30 GOLF PERFORMANCE AND INJURY PREVENTION 30 Figure 1: C-Spine posture at initial set up position Figure 2: Loss of posture swing fault at initial contact

31 GOLF PERFORMANCE AND INJURY PREVENTION 31 Figure 3: Early extension swing fault at initial contact

32 GOLF PERFORMANCE AND INJURY PREVENTION 32 Golf Program This program was designed to fulfill all necessary aspects of golf specific strength and conditioning. Flexibility and strengthening were highlighted in this periodized program. To properly prepare for an event, an athlete utilizes a periodization program. Periodization programming consists of progressive increases and cycling of performance variables according to expected outcomes. This type of training will allow for peaks to be established around competitive events. This program is not intended to be used as a template for all golfers. However, the program presented is intended to be used as an example of what a golf specific periodization program should resemble. Each sport has its own specific physiological profile and characteristics. It is important to understand the different energy systems and how they apply to sport specific training when designing a golf specific program. Specific development of necessary biomechanical ability must have a method. One must develop an exercise program which resembles the specifics of the sport in order to comply with the principle of specificity. Since the golf swing is composed of movements which are more complex, the strength program utilized should be viewed as the mechanism required to perform skill rather than just for strength development. Just like with any other program, exercises and variables can and should be adjusted to meet the level of exercise experience and functional/physical limitations of each individual. One must always remember to follow the principle of specificity when training for golf. Golf specific exercises should consist of quick functional power movements and functional balance theories. There have been several studies that demonstrate the influence golf specific programming can

33 GOLF PERFORMANCE AND INJURY PREVENTION 33 have on golfers of all ages and levels. However, some people find it difficult to understand what is actually required out of a golf specific program. There is a common theme throughout this program: increase stability of the lower body and increase mobility of the upper body. Lower body stability will be accomplished through hip balance and strengthening exercises coupled with tissue extensibility techniques. Also, trunk rotation is a focus point because of the obvious relationship with the swing itself. By using the rotational strengthening component, our goal is to establish motor learning. Any increase in rotational efficiency at this point can be considered a result of improved neuromuscular function. It is possible for nearly every golfer to reach the physical peak they are seeking. However, in order to do so there needs to be optimization of certain physical characteristics. Strength, flexibility and balance need to be the main focus throughout. Results Subjective Prior to initiating the program, Mr. Smith s goal was to decrease pain to 2-3/10 by 6 weeks and be able to complete a round of golf with minimal to no pain in 12 weeks. By week 10 Mr. Smith was able to complete a full round of golf with minimal to no pain in bilateral hips. Mr. Smith no longer reports pain during golf swing and reports increased ability to produce consistent power throughout all 18 holes. Muscular endurance was a limiting factor in both power and accuracy pre-programming; however, Mr. Smith reports feeling as if he is striking the ball better than he ever has. Muscle recovery is reported to have improved post activity and he now has the ability to play consecutive days without limitations in performance. Mr. Smith continues to maintain corrective exercise program and pre-rehabilitative exercise protocol every other day.

34 GOLF PERFORMANCE AND INJURY PREVENTION 34 Golf Specific Physical Evaluation Pelvic Tilt Test: Starting pelvic tilt- Reduced C-Posturing Arching/Flattening has improved: No shake and bake movement Pelvic Rotation Test: Improved (left rotation into lead hip) Torso Rotation Test: Minimal lateral sway: improved mobility Overhead Deep Squat Test: Right DF continues to be limited; arm down full squat Toe Touch Test: Limited toe touch bilateral improved 90/90 Test: Right Standing: Equal to spine angle improved ROM and stability in golf posture Left Standing: Equal to spine angle improved ROM and stability in golf posture Wrist Four Ways Test: WNL Single Leg Balance Test: 10 seconds bilateral Lat test: covers the nose bilateral Cervical Rotation Test: limited bilateral Seated Trunk Test: Equal to 45 degrees bilateral (ER Rt Downswing; IR Rt Backswing) Half-Kneeling Rotation Test: 45 bilateral bar behind back equal to bar in front Thomas Test: Decreased quadriceps tightness bilateral Hip Abduction Test: Glute medius force production increased drastically (decreased sway/slide) Leg Lowering Test: Pressure drops below 40 lbs with core activation Bridge with Leg Extension Test: Glute Normal Bilateral Active Straight Leg Raise Test: 68 degrees right, 65 degrees left Hip Rotation Test: 40 int. and 43 ext. right, 38 int. and 48 ext. left

35 GOLF PERFORMANCE AND INJURY PREVENTION 35 Discussion Summary of Findings The increase of external rotation and strength in bilateral hips allows Mr. Smith to swing the club more consistently and with increased power. Shoulder range of motion improvements and decreased stability/mobility concerns allow him to now swing the club around his body and elicit proper downswing sequencing in order to create power with his core musculature instead of secondary musculature. Improved sequencing and core musculature not only improved overall power/strength, but also improved ability to replicate swing and provided accuracy. The improved ability to demonstrate rotary power has now reduced reliance on upper extremities and allows disengagement of arms and hands in the golf swing. A larger shoulder movement with a settling of the upper body has led to a dramatic improvement in consistency based on reported findings during play. Before the start of the conditioning program, lack of thoracic spine extension was limiting backward bend or arching of the lower back. T-spine mobility restriction led to loss of spinal rotation and inhibited a full backswing. Mr. Smith s torso can now rotate and reduce sway/slide which was an issue at the start of the program. By strengthening bilateral hips, Mr. Smith is able to move his pelvis in a true rotatory motion instead of producing lateral sway which hinders golf performance and stresses surrounding musculature. The dramatic increase in stability demonstrated post programming allows Mr. Smith to be well balanced in all phases of the golf swing. Mr. Smith has also developed confidence in using his hips to produce power. C-spine continues to be somewhat of a concern, but has been reduced. Overall hip strength and range of motion has improved. Gluteal muscle activation is now properly produced and utilized in the golf swing. Hip flexor tightness decreased bilaterally. Mr. Smith is now able

36 GOLF PERFORMANCE AND INJURY PREVENTION 36 to perform bilateral gluteal bridges with leg extensions. Neuromuscular facilitation of core musculature improved with reports of increased control during closed chain activities which require lateral pelvic motion. Ability to control and maintain pelvic stability while performing exercises and TPI screen has improved and shake and bake motion has decreased. Mr. Smith subjectively reports 0-1/10 pain during and post golf activity. Loss of posture swing fault is no longer exhibited secondary to improved base of support control and improved soft tissue restrictions. Early extension swing fault no longer exhibited. Internal rotation of lead hip now allows his lower body to fully rotate without forward motion towards the ball. Pelvis remains able to rotate around the lead hip with no joint/soft tissue restrictions.

37 GOLF PERFORMANCE AND INJURY PREVENTION 37 References Behm, D. G., & Sale, D. G. (1993, June). Velocity specificity of resistance training. Sports Medicine, 15(6), Retrieved from Brandon, B., & Pearce, P. Z. (2009, May/June). Training to prevent golf injury.. Current Sports Medicine Report, 8(3), Retrieved from Chen, B., Lam, W.K., Mok, D., Yeung, F., Hung, J., Dale, R.B. A three-week conditioning program for improved golf performance. Athletic Therapy Today, 2010 Jul; 15 (4): Cochran & Stobbs. The search for the perfect swing. Philadelphia (PA): Lippincott. Doan, B.K., Newton, R.U., Kwon, Y.H., Kraemer, W.J. Effects of physical conditioning on intercollegiate golfer performance. J Strength Cond Res Feb; 20(1): Farrally, M. R., Cochran, A. J., Crews, D. J., Hurdzman, M. J., Price, R. J., Snow, J. T., & Thomas, P. R. (2003, September). Golf science research at the beginning of the twentyfirst century. Journal of Sports Science, 21(9), Retrieved from Fletcher, I.M., Hartwell, M. Effect of an 8-week combined weights and plyometrics training program on golf drive performance.j Strength Cond Res Feb; 18(1): Fradkin, A.J., Sherman, C.A., Finch, C.F. Improving golf performance with a warm up conditioning programme.br J Sports Med Dec; 38(6): Gordon, B.S., Moir, G.L., Davis, S.E., Witmer, C.A., Cummings, D.M. An investigation into the relationship of flexibility, power and strength to club head speed in male golfers. J Strength Cond Res Aug; 23(5): Jobe, Moynes &Antonelli Rotator cuff function during a golf swing. Am J Sports Med 1986; 14 (5): Kao, Pink M, Jobe FW, Perry J. Electromyographic analysis of the scapular muscles during a golf swing. Am J Sports Med 1995; 23: Keogh, J.W.L., Marnewick, M.C., Maulder, P.S., Nortje, J.P., Hume, P.A., Bradshaw, E.J. Are anthropometric, flexibility, muscular strength, and endurance variables related to clubhead velocity in low- and high-handicap golfers? J Strength Cond Res Sep; 23(6):

38 GOLF PERFORMANCE AND INJURY PREVENTION 38 Lehman, G. J. (2006, March). Resistance training for performance and injury prevention in golf. The Journal of the Canadian Chiropractic Association, 50(1), Retrieved from Lephart, S. M., Smoliga, J. M., Myers, J. B., Sell, T. C., & Tsai, Y. S. (2007). An eight-week golf-specific exercise program improves physical characteristics, swing mechanics, and golf performance in recreational golfers. Journal of Strength and Conditioning Research, 21(3), Retrieved from lfspecificexerciseprogram.pdf McHardy, A., Pollard, H., & Luo, K. (2006). Golf injuries: a review of the literature.. Sports Medicine, 36(2), Retrieved from Pink, Perry& Jobe Electromyographic analysis of the trunk in golfers. Am J Sports Med 1993; 21 (3): Reed, J. (2005, April). Strength and conditioning strategies to reduce the risk of lower back injuries associated with the golf swing. Strength and Conditioning Journal, 27(5). Retrieved from Strength_and_Conditioning_Strategies_to_Reduce_the.1.aspx Ronda, L. T., Medina, L. S., & Gonzalez-Badillo, J. J. (2011). Muscle strength and golf performance: a critical review. Journal of Sports Science and Medicine, 10, Retrieved from Sell, T.C., Tsai, Y.S., Smoliga, J.M., Myers, J.B., Lephart, S.M. Strength, flexibility and balance characteristics of highly proficient golfers. J Strength Cond Res Nov; 21(4): Sherman, C. A., & Finch, C. F. (2000, March). Preventing injuries to competitive and recreational adult golfers: what is the evidence?. Journal of Science and Medicine in Sport, 3(1), Retrieved from Smith, C. J., Callister, R., & Lubans, D. R. (2011, June). A systematic review of strength and conditioning programmes designed to improve fitness characteristics in golfers. Journal of Sports Science, 29(9), Retrieved from Stemm, J.D., Jacobson, B.H., Royer, T.D. Comparison of stability and weight shift among golfers grouped by skill level. Percept Mot Skills Dec; 103(3):

39 GOLF PERFORMANCE AND INJURY PREVENTION 39 Thompson, C. J., Cobb, K. M., & Blackwell, J. (2007, February). Functional training improves club head speed and functional fitness in older golfers.. Journal of Strength and Conditioning Research, 21(1), Retrieved from Thompson, C.J., Osness, W.H. Effects of an 8-week multimodal exercise program on strength, flexibility, and golf performance in 55- to 79-year-old men.j Aging Phys Act Apr; 12(2): Watanabe, K., Saito, M., & Hokari, M. (n.d.). Golf skill and swing motion. Retrieved from /Papers/Topic%2018/Watanabe.PDF Wells, G. D., Elmi, M., & Thomas, S. (2009, May). Physiological correlates of golf performance. Journal of Strength and Conditioning Research, 23(3), Retrieved from

40 GOLF PERFORMANCE AND INJURY PREVENTION 40 Appendix: Periodized Golf Fitness Program

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