Golf has remained an extremely popular sport in the last century, with over 25 million Americans now playing on greens across the country. Peruse any sports medicine journal or magazine and you will find numerous articles related to golf injuries and fine tuning a golfer’s game. In what has been standard for professional sports leagues such as the NFL, all three major professional golf tours now include vans full of physical therapists, athletic trainers, and physicians ready to assist during the tournaments. Current day golf has become a serious hobby with myriad injuries. This article will examine the kinesiology of the golfer, and discuss the common injuries associated with golf.
To assist the therapist in proper treatment of a golf-related injury, it is important to understand the biomechanics of the golf swing.
The beginning phase of a golf swing is called the setup phase, and is very important for an accurate and powerful swing. As the golfer takes his stance, the torso is flexed forward to create the primary spinal angle. The hip joints serve as the axis of rotation, while the mid trunk and thigh serve as lever arms to form the angle. The secondary angle is formed by a combination of lateral bending to the right (for right-handed golfers) in the spinal segments. There is a slight depression of the arm and scapula as the shoulders roll forward slightly to grip the club. Analysis of high speed video of professional golfers shows the primary angle is approximately 45°, and the secondary angle approximately 16°.
When a golfer swings, his center of rotation is stabilized by the constant primary and secondary angles. This is part of the skill of a golf swing; maintaining both spinal angles and achieving a complete 90° shoulder turn and a 45 ° hip turn make the swing powerful. For the golfer to achieve the full range of motion during the swing, he must be flexible in his hips, shoulders, and torso. Limitations in any of these areas results in a limited swing with compensation from other muscles. In fact, flexibility is the main factor in how powerful the golfer’s swing is. For example, if the golfer’s spinal rotators are limited in range of motion, he will not achieve the dynamic twisting that is necessary in the swing phase. Watch any amateur golfer at a local course and you will see the difference. When the body is compensating it just does not look natural.
Amateur golfers tend to move their hips and legs more lateral, causing the secondary spinal angle to be lost. Instead of rotating the pelvis in synchronization with the shoulders, they laterally shift the lower body in an effort to increase club speed on the downswing. Most of the weight of the golfer is placed on the front foot instead of the back foot, and this forces the golfer to try and get her upper torso behind the ball. From this position, the golfer must adjust her position by sliding the hips back laterally toward the target. The spine is forced to flex laterally to the involved side (right or left) to reestablish the original inclination. Shear and rotational forces act on the spine during this movement, and the combination can cause extreme hyperextension of the spine during the late stages of the swing. Many injuries that I have treated occurred during this late swing phase.
A familiar golf theory in sports medicine is that the larger muscles of the body—gluteals, latissimus, pectoralis—provide much of the power needed in the golf swing. It is not a bad theory, given the importance of using the entire body to prevent excessive forces on the skeleton or other smaller muscles. This is certainly true for many sports activities. The problem in applying this theory in golf is that it can cause too much lateral movement in the golfer’s base of support, and it adds a rotary movement during the swing. The result can be a distortion in the swing, and excessive forces on other parts of the body. Injuries are sure to follow.
So if it is not in the golfer’s best interest to use the entire body, what should she do? First of all, having a solid base, or “core,” is important in any type of movement. Golf is no exception. Let me explain. The key here is to have complete overall body strength and flexibility. Professional golfers on the circuit today train year round with exercises that target complete core movements. The golf swing is an unnatural movement, theoretically, yet so is the baseball batter’s swing. I have heard this many times by other colleagues: “The body is not meant for golf.” It is and it isn’t. Consider this: Golfers with a greater degree of rotational swing (those that appear like a windmill) will generally require more demanding support from the shoulders, arms, and hands. Golfers that have more lateral movement will require greater abdominal strength and lower back stability. If a body is not conditioned for golf– as most bodies are not—it will not handle excess forces and rotary movements well. The human body can move safely in any plane against any forces if it is conditioned to do so.
During impact in the golf swing, the arms, hands and club should nearly return to the start position. Many sports medicine journals suggest that both wrists should remain cocked until the last instant for maximum speed. Some golf pros insist uncocking the wrist decelerates the golfer’s swing, hindering a more powerful stroke. What is important here is that the force created during a live swing will cause both wrists to deviate toward the ulnar direction. The left wrist goes into flexion as the hands near impact phase, creating a lengthening of the extensor muscles and a pull on the lateral epicondyle. Lateral epicondylitis, or “golfer’s elbow,” is a typical golf injury that results from wrist flexion during the swing. It is one of the most common injuries therapists see, especially in weekend athletes.
Limitations of shoulder motion, especially in the posterior cuff, add additional loads to the muscles. In a very short span of time, the soft tissues of the shoulder are shortened and lengthened rapidly, and in the course of golf, over and over. At the same time, they are also absorbing contact forces from the ground and ball during impact. DeQuervain’s syndrome, or tendinitis of the extensor and abductor muscles of the thumb, is common in golfers. It usually goes hand in hand with golfer’s elbow, as the limited tissue causes more intense forces on these tissues.
Another major problem with a golfer’s biomechanics is limitations in thoracic rotational flexibility. If a golfer cannot obtain a normal range of motion, she will compensate with other muscles. Tightness in a rotary motion is extremely dangerous for the thoracic and lumbar disks, as well as soft tissues. A golfer with limited mobility in her thoracic cage will need to produce more rotation in her lumbar spine and hips to produce the full motion. This situation creates extreme rotational torques in almost every part of the body. With continued playing, of course, these forces slowly “chip away” at the protective structures of the body, eventually causing injury or loss of movement.
Since a golfer’s biomechanics so predict future injuries, one of the best areas a therapist can focus on is his flexibility. Clinical Flexibility and Therapeutic Exercise (CFTE) consists of a series of specific exercises that target problem areas. Limited tissue is opened and range of motion restored. These exercises are catered to each individual, and are easily learned and imported into a massage therapist’s tool box. Without proper range of motion (ROM), a golfer is susceptible to countless injuries and poor performance in the game. If I could assign the most important part of the body to focus on, it would be the thorax and hips. Without proper ROM in these areas– rotation, flexion, and extension, respectively— a golfer has no chance to remain injury-free. The shoulders, too, will compensate if the core of the body is unstable or limited. While I treat the entire body of the athlete, treating isolated parts can be of great help, especially if time is short.
Begin by assessing the ROM in the patient’s thoracic rotation. This can be done with the patient in a chair, or sitting on the table. Ask him to sit as straight as possible and turn to the right and left with his torso. If there is any restriction or it is difficult for him, this is a good place to start. A good CFTE stretch involves having the patient perform the movement of thoracic rotation while seated, with the therapist assisting in the stretch at the end of the movement. Muscles that should be opened here include the rotators, spinalis, latissimus, and rectus abdominis. Rotation is something that takes time to change, so take it slowly and perhaps do a set of 8 active rotations after the massage. A little goes a long way. Teach the golfer how to perform this stretch before his golf game. In the CFTE protocol, we are always educating the patient on how he can perform the exercises himself. He can do this stretch from any bench or even in the golf cart. Explain why it is important so that he understands the value of the exercise.
How does your golfer walk? Are there limitations in gait? Assess the hips during your massage, or after if it is more comfortable for the patient. You can assess by moving the hip in every direction it should move: abduction, adduction, flexion, and hyperextension. Feel and look for restrictions. It is especially important to look at the psoas muscle. If your golfer cannot achieve –15 degrees of hyperextension in the hips while lying prone, you must open the psoas muscle using an active stretch. A good way to do this is by having the patient kneel on one knee, with the other leg flexed forward. The torso remains straight as he leans into the stretch. The support foot should be positioned so that the knee does not move over it during the movement to protect the knee joint. Show him how to perform this kneeling psoas stretch, and again be specific on when he should do the stretch. The best time is in the morning and always before he plays golf.
If time is an issue and you cannot perform many assisted stretches, stretch the gastrocnemius at the very least. Another valuable and easy stretch are the gluteals. I usually teach the athlete both of theses stretches as a minimum routine.
As a therapist, you are in a position to really help the golfer avoid the common weekend injuries, and to improve his or her movement for a lifetime.
For more information, his web site is www.stretchme.com.