Exercises for Improving Hip Rotation USE OF GOLF SPECIFIC

Transcription

Exercises for Improving Hip Rotation USE OF GOLF SPECIFIC FUNCTIONAL ASSESSMENT AND EXERCISES FOR
IMPROVING RIGHT HIP INTERNAL ROTATION LIMITATIONS IN A RIGHT
HANDED GOLFER
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
Raymond N. Agostino
2015
Exercises for Improving Hip Rotation APPROVAL SHEET
This case report is submitted in partial fulfillment of
the requirements for the degree of
Doctor of Physical Therapy
__________________________________
Raymond N. Agostino
Approved: May 2015
___________________________________
Shawn D. Felton, EdD, ATC, LAT
Committee Chair / Advisor
___________________________________
Stephen A. Black, D.Sc, PT, ATC/L, NSCA-CPT
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.
Exercises for Improving Hip Rotation
Acknowledgements
I would like to thank Darin Hovis, ATC, ACE Certified Personal Trainer, Titleist
Performance Institute Certified Level 3 Golf Medical and Fitness Professional, for
supervising the assessments and interventions performed as part of this case report. I
would also like to thank Dr. Shawn D. Felton, EdD, ATC, LAT and Dr. Stephen A.
Black, D.Sc, PT, ATC/L, NSCA-CPT for their continued guidance and support. I would
also like to thank my wife, Noelle Agostino, for her unwavering support and patience
throughout this entire process. This would not have been accomplished had it not been
for her encouragement.
Exercises for Improving Hip Rotation 4
Table of Contents
Abstract
6
Introduction / Background
8
Figure 1: Number of U.S. Golfers, projected to 2020
8
The Golf Swing
Phases of the golf swing
10
Figure 2: Phases of the golf swing
10
Figure 3: Leading towards target with hip rotation
11
Trailing Hip Biomechanics
12
Backswing
12
Downswing
13
Hip rotation benchmarks
13
Trailing Hip Limitations & Dysfunctions
14
Golf -related injuries
Analysis & Interventions
14
15
Intervention programs
15
Client History / Review of Symptoms
17
Clinical Impression
Examination
18
18
Tests and Measures
18
Functional Screening
18
Hip Active ROM
19
Hip MMT
19
Numeric Pain Rating Scale
20
Figure 4: Numeric Pain Rating Scale
20
Table 1: Physical Examination Key Findings
21
Clinical Impression
21
Intervention (Application of Theory to Practice)
22
Outcomes
22
Discussion
23
References
25
Appendices
Appendix A: Titleist Performance Institute (TPI) Screen
27
Appendix B: Specific Exercises
33
Abstract
Background: Greater range of motion for hip internal rotation in the trail (right)
hip of a right-handed golfer is a characteristic shared by golfers who are sub-10 handicap
players (Sell, Tsai, Smoliga, Myers, & Lephart, 2007). Improving right hip internal
rotation can be an effective way of improving the proficiency of an amateur golfer.
Client History: A 42-year-old male consulted his sports medicine specialist because of
decreased bilateral hip range of motion and bilateral hip pain that he determined to be the
cause of his increased golf handicap index. He was referred to outpatient fitness training
where he revealed that his pain symptoms were: prolonged sitting and walking, multiple
golf swings, and playing golf for longer than one hour. During the time of initial
assessment, the client reported that no previous interventions had been provided.
Examination: As part of the initial assessment, a TPI Certified Level 3 Golf Medical
and Fitness Professional administered a Titleist Performance Institute (TPI) functional
screen. This functional screen consisted of sixteen separate assessments to determine the
clients golf fitness level, and was used to decide prescribed exercise interventions.
Additional assessments included objective measurements of bilateral active hip flexion
and internal rotation range of motion, manual muscle testing of bilateral hip flexion,
internal and external rotation, as well as conducting a self reported numeric pain rating
scale survey. Intervention: The intervention plan consisted of twenty-four treatment
sessions over an eight-week period. Each session entailed completing ten dynamic
exercises, all of which were supervised by the assessing TPI professional. These
exercises focused on increasing bilateral hip mobility and strength. Outcomes:
Objective measurements were taken again at the end of the eight weeks, and there were
noted increases in strength and range of motion, as well as a pronounced decrease in pain
levels. Discussion: This case illustrated the potential for specific exercises based on a
functional assessment to improve measurable aspects of golf performance.
Introduction/Background
Golf has become an increasingly popular and distinctive sport for players of all
ages, sex, and athleticism. A 2003 report stated there were over
55-million golfers
worldwide (Lephart, Smoliga, Myers, Sell & Tsai, 2007). In 2011, the National Golf
Foundation reported that golf attracted approximately 25.7 million participants in the
United States alone. This number is expected to reach approximately 30.2 million by the
year 2020 (National Golf Foundation, 2012). Figure 1 identifies the number of golfers in
the United States from the year 1986, projected to the year 2020.
Figure 1. Number of U.S. Golfers, projected to 2020 (National Golf Foundation, 2010).
Along with the increase in number of golf participants, there has also been an
increase in the length of time that individuals are playing golf. Age has been shown to
have a limited effect on high performance and skill, and a golf career can last for more
than 50 years (Cabri, Sousa, Kots & Barreiros, 2009). Several techniques to improve
longevity and performance in golf have been implemented, and three specific techniques
have been described in recent studies. One method that golfers are using to improve
performance is purchasing equipment with the latest technology. According to a report
from the National Golf Foundation, $5.639 billion was spent on golf supplies, including
equipment, in the year 2011.
A second method being used is the improvement of swing
mechanics, as taught by PGA professionals or certified golf instructors. This type of
instruction can reduce swing faults and allow for a more reproducible swing. PGA
professionals can also help improve individual aspects of a golfer’s game, such as
driving, chipping, and putting. A third method of golf improvement being utilized is the
enhancement of swing biomechanics. Physical training, as prescribed by movement
professionals, such as physical therapists, athletic trainers, or strength and conditioning
coaches, has been shown to improve the biomechanics needed for the golf swing, thus
improving specific golf performance measurements, such as clubhead speed and ball
speed. Achieving these proper biomechanics requires a combination of balance,
flexibility, and strength to combine the movements of several segments of the body (Sell
et al., 2007).
The Golf Swing
Each golf swing can be described as a variation of one of two swing styles. One
is called the modern golf swing and the other is called the classic golf swing. Each of
these swings requires distinctive biomechanics that have different effects on the range of
motion of various joints of the body (McHardy, Pollard, & Bayley, 2006). Healy et al.
(2011) supported the hypothesis that differences in joint kinematics are evident between
golfers who achieve a greater hitting distance and those who achieve a lesser hitting
distance. This was also supported by Chu, Sell, & Lephart (2010), who described swing
mechanics as the most important for optimal golf driving performance. The classic golf
swing promotes hip rotation and decreases the torque on the lower back. Lifting the front
heel during the backswing, completing a shorter backswing, or a combination of these
two methods, results in increased hip rotation. The modern swing demands a greater
shoulder turn while keeping the hips relatively restricted. The greater shoulder turn and
relative restriction of the hips is a result of maintaining a flat front foot during the swing,
therefore decreasing the motion in the lower extremities throughout the swing (McHardy
et al., 2006).
Phases of the golf swing. Incorporated within each of these swing styles are
three phases of the golf swing that can be examined using functional movement analysis.
The swing phases are the backswing, the downswing, and the follow-through (Figure 2).
Some authors include an acceleration phase and impact phase that occur between the
downswing and follow-through, in order to further breakdown the biomechanical motions
needed to produce an effective golf swing (Chu et al., 2010).
Figure 2. Phases of the golf swing.
(1) backswing (2) downswing (3) follow-through
The goal of the backswing is to position the golfer’s center of mass and clubhead to
produce a great amount of potential energy in preparation for the downswing (Hume,
Keogh, & Reid, 2005). This coiling mechanism of the backswing involves a separation
between the upper torso and pelvis, and the purpose is to store energy that eventually is
released to produce clubhead speed at impact (McHardy et al., 2006). According to
Burden, Grimshaw, and Wallace (1998), the upper body begins to rotate away from the
target before the hips at the start of the backswing. The duration of the backswing in elite
golfers is less than one second, resulting in 60-80% of weight transferring to the right
side, or trailing side, assuming a right handed swing (Hume et al., 2005). The
downswing begins just prior to the completion of the backswing, and is initiated by an
uncoiling mechanism, lasting approximately 0.30 seconds +/- 0.06 seconds. Left pelvic
rotation begins towards the target before the arms complete the backswing (Figure 3), and
the uncoiling mechanism continues throughout the downswing.
Figure 3. Leading towards target with hip rotation.
The kinetic chain reaction of the downswing continues with the uncoiling of the trunk
and shoulders, and ends with the wrists and hands. This transition promotes a whipping
action at the shoulders, which extends distally to the hands, and as a result, the golf club.
Burden et al. (1998) described this phenomenon as the ‘summation of speed principle’,
stating that the maximum speed of hip rotation is followed by a greater maximum speed
of shoulder rotation during the downswing. In 75% of golfers studied, the downswing
began while the shoulders continued rotating away from the target as the hips began
rotating back towards it. Following the downswing phase, the follow through phase
begins after impact with the golf ball. Immediately following impact, eccentric muscle
action is used to decelerate the body and the clubhead (McHardy & Pollard, 2005). As
the follow-through continues, there is a proximal to distal deceleration of the body,
allowing for a controlled completion of movement. The full follow-through swing phase
is a continuation of the follow-through, and begins when the club is horizontal to the
ground.
Trailing Hip Biomechanics
Backswing. The coiling action of the trailing hip during the backswing phase of
the golf swing is the result of the right hip going through flexion, adduction, and internal
rotation, and ending in a flexed, adducted, and internally rotated position, respectively.
The most active muscles in the right hip during the backswing coiling mechanism are the
semimembranosus and the long head of the biceps femoris, with 28% and 27% of
maximal manual testing recruitment, respectively (McHardy & Pollard, 2005). To
produce these motions, internal peak hip torques generated during flexion, adduction, and
internal rotation are 6.56 Nm +/- 1.73, 4.95 Nm +/- 1.88, and 2.7 Nm +/- 1.15,
respectively (Foxworth et al., 2013).
The motions of the right hip during the backswing
can be limited by ligamentous structures including: the iliofemoral, pubofemoral,
ischiofemoral, ligamentum teres femoris, and the ligamentum orbicularis (Torry,
Schenker, Martin, Hogoboom, & Philippon, 2006).
Downswing. The transformation from the backswing to the downswing is
initiated in the right hip by extension, abduction, and external rotation. The hip extensors
and abductors of the right hip initiate the powerful left pelvic rotation to start the
downswing. The muscles with the greatest level of activation during this transition are
the upper and lower gluteus maximus, with 100% and 98% of maximal manual testing
recruitment, respectively (McHardy & Pollard, 2005). To produce these motions,
internal peak hip torques of this powerful uncoiling are 10.64 Nm +/- 1.96, 5.69 Nm +/1.21, and 2.38 Nm +/- 0.84 for hip extension, abduction, and external rotation,
respectively (Foxworth et al., 2013). All of these factors work simultaneously to
optimize the biomechanics of the hip joint and create proper transitioning from one swing
phase to the next.
Hip rotation benchmarks. Burden et. al. (1998) determined that seven out of
eight golfers rotated their hips between 35 degrees and 48 degrees. The entire study
population also counter-rotated towards the target through a range of 52 degrees +/- 17
degrees prior to impact. The hips account for approximately 10% of the linear velocity
produced in the downswing, a direct result of peak hip torques at the transition between
the backswing and the downswing. Foxworth et al. (2003) demonstrated that the
correlations between club-head velocity and peak hip torques during the backswing were
r=0.64 (p=0.002), r=0.56 (p=0.01), and r=0.56 (p=0.01) for internal rotation, flexion, and
adduction, respectively. During the initiation of the downswing, the correlation values
were r=0.60 (p=0.005), r=0.46 (p=0.042), and r=0.09 (p=0.712) for external rotation,
extension, and abduction, respectively. Limitations and dysfunctions that negatively
affect a golfer’s swing can be observationally analyzed and corrected to create the proper
biomechanical balance needed to swing more effectively.
Trailing Hip Limitation & Dysfunction
An indication of limited external pelvic rotation in the trailing hip of a righthanded golfer is an anterior tilt of the pelvis as the result of increased hip flexion.
Relative right hip internal rotation during the backswing of less than 30 degrees will
cause the pelvis to ascend and shift laterally to the right. This lateral shift reduces the
amount of club-head speed available following the backswing transformational zone. A
common compensation for this dysfunction is a toeing out of the feet of 10–20 degrees as
a means to promote proper hip coiling (Hume et al., 2005). The rotation of the pelvis to
the left into the downswing occurs prior to the arms and shoulders completing the
backswing. This forces the right hip into external rotation during axial loading and drives
the femoral head anteriorly, over time, this action can result in anterior capsular laxity,
elastic changes of the iliofemoral ligament, acetabular labrum tears, and frequently
chondral delamination (Torry et al., 2006). In addition to injuries, trailing hip limitations
create a reduction in club-head velocity.
Golf-related injuries. Cabri, Sousa, Kots, & Barreiros (2009) determined that
injuries sustained from playing golf originate from overuse or from traumatic causes.
Between 25.2 and 62.0% of all amateur golfers are injured on an annual basis, primarily
occurring at the elbow, wrist, shoulder, and dorso-lumbar sites. Studying 643 amateur
golfers, Gosheger et al. (2003) found that 255 reported a total of 527 injuries. These
injuries resulted in a total of 18,221 lost days of golfing and were mostly related to
overuse or trauma. The most common regions of the body affected by injury in amateur
golfers were the elbow, back, and shoulder, respectively.
Injuries to the trailing hip
were found to be far less common, resulting in only 20.5 days of golf lost over a period of
two golfing seasons. Comparatively, thoracic spine injuries resulted in 137.4 days lost,
elbow injuries resulted in 73.8 days lost, and ankle/foot injures cause an absence of 55.9
days. Because of biomechanical stresses placed on the musculoskeletal tissue, different
phases of the golf swing may cause different patterns of injury, especially when
anomalies of posture and technique are present.
Analysis & Interventions
In order to determine any biomechanical limitations in the golf swing, a
functional movement analysis using qualitative biomechanics, or observation, should be
performed. This qualitative analysis is used to evaluate the biomechanical effectiveness
of the golf swing and to provide appropriate feedback in order to develop an intervention
for musculoskeletal limitations. Based on biomechanical principles, a theoretical model
of swing phase transitions should be performed and then compared with the observed
golf swing. Through analysis of this comparison, causes of any deficiencies can be
determined. The analysis is focused first on the swing as a whole before it is then applied
to the individual swing phases (Hume et al., 2005). Any range of motion or strength
dysfunctions can be addressed with specific exercise interventions.
Intervention programs. Increasing flexibility has conventionally been stressed
in golf specific exercises as a way to improve range of motion throughout the swing.
Improved flexibility allows for more mechanical work to be achieved throughout the
swing, therefore increasing club head speed at impact (Gordon, Moir, Davis, Witmer, &
Cummings, 2009). Sell et al. (2007) examined the strength, flexibility, and balance
characteristics of highly proficient golfers. The study determined that lower handicap
golfers had significantly greater isometric strength, as measured by a Biodex System 3, in
right hip abduction, right hip adduction, and left hip abduction. The lower handicap
golfers also demonstrated significantly greater range of motion, as measured by a
standard goniometer, in right hip extension, left hip flexion, and left hip extension.
Keogh et al. (2009) determined relationships between flexibility, muscular strength and
endurance and clubhead velocity in low and high handicap golfers. The results suggested
that low handicap golfers generated 12% greater club-head velocity, 28% greater golf
specific cable wood chop strength, and 30% greater bench press strength, but 24% less
right hip internal rotation strength. Lephart et al. (2007) examined the relationship
between range of motion and golf performance, as measured by club-head velocity. The
study examined the effects of an eight-week golf-specific exercise program to improve
range of motion, including the hip motions of flexion, extension, abduction, and
adduction. The training program included stretching exercises and both concentric and
eccentric strengthening exercises aimed to increase balance and hip strength while
improving hip flexibility. At the end of the program, the measured hip ranges of motion
exhibited significant improvements. These improvements resulted in increased clubhead
speed, ball speed, carrying distance and total ball distance. The varying factors that were
also affected by this exercise program must be taken into consideration. It was concluded
that flexibility and strength improvements lead to a 5.2% improvement in clubhead
velocity. These analysis techniques and interventions can be used to limit and or
overcome joint dysfunctions that arise during the golf swing. They also provide a means
to improve biomechanics throughout the swing and to improve golfer performance.
Client History/Review of Systems
The client was a 42-year-old male client referred to outpatient fitness training
after consultation from a sports medicine specialist. Prior to his referral, the client
reported having bilateral hip pain and decreased bilateral hip range of motion. Diagnostic
imaging reports from the sports medicine specialist were unremarkable. During his
initial fitness assessment, the client also reported a decrease in his golf handicap index.
Aggravating factors were identified as prolonged sitting, prolonged walking, bilateral hip
internal rotation, which was required for golf activities, playing golf for longer than one
hour, and swinging his driver, 3-wood, 5-wood, 4-iron, and 5-iron. He also stated that he
has been symptomatic for at least six months and that he has not played any golf for at
least three. Alleviating factors included the use of ibuprofen, short rest periods, and heat,
as per patient self-report. Comorbidities included history of low back pain and left knee
pain, as reported by the client. He had not received any previous interventions prior to
initial fitness training evaluation. The client’s primary goal for golf fitness training was to
be able to resume his previous golfing activities, which included playing at a higher level
and completing multiple rounds over a three-day span without reports of symptoms.
Clinical Impression
Based on the subjective data provided, this client was a candidate to undergo a
functional golf specific functional assessment to determine whether he would be
appropriate for this approach. Qualifying factors included: bilateral hip pain and
decreased bilateral hip range of motion, decreased club head speed, self reported fatigue
following a round of golf, and an increase in golf handicap index. In addition to the golf
specific functional assessment, further examinations to determine appropriateness of this
client included objective range of motion (ROM) measurements of his bilateral hip
flexion and bilateral hip internal rotation, as well as manual muscle testing (MMT) of his
bilateral hip flexors, and hip internal and external rotators and a Numeric Pain Rating
Scale (NPRS) for bilateral hip pain.
Examination
Tests and Measures
Functional screening. The initial examination was initiated with a Titleist
Performance Institute (TPI) Screen to determine the client’s fitness handicap. A TPI
Certified Level 3 Golf Medical and Fitness Professional administered this golf specific
functional screen. The TPI medical certification gives medical professionals golfspecific injury assessment and rehabilitation techniques. These professionals examine
how to access and treat injuries and how specific physical limitations can be addressed to
improve performance. The TPI Screen consists of sixteen separate assessments that are
subjectively measured and used to establish a baseline golf fitness level. Assessment
descriptions and initial findings are provided in Appendix A. The findings of the TPI
screen were based on the client’s ability to do the movements, as well as the quality of
the movement patterns. The sixteen movements that were assessed included: (1) pelvic
tilt test, (2) pelvic rotation test, (3) torso rotation test, (4) overhead deep squat test, (5) toe
touch test, (6) 90/90 test, (7) single leg balance, (8) the latissimus dorsi test (shoulder
flexion test), (9) lower quarter rotation test, (10) seated trunk rotation test, (11) bridge
with leg extension test, (12) cervical rotation test, (13) forearm rotation test, (14) wrist
hinge test, (15) wrist flexion test, and (16) wrist extension test.
Hip active ROM. Hip flexion ROM was performed in the supine position using
a Jamar E-Z Read 12 ½” goniometer. Hip internal and ROM were performed with the
same goniometer in the sitting position. For all ROM measures, the client was asked to
move as far as possible through the range. Initial and follow-up ROM findings are
provided in Table 1. At the initial evaluation, active ROM measurements were recorded
for right and left hip flexion and internal rotation. The client produced 90 degrees of
right hip flexion, 15 degrees of right hip internal rotation, 60 degrees of left hip flexion,
and 22 degrees of left hip internal rotation. According to the American Academy of
Orthopedic Surgeons, normal range of motion values for flexion and internal rotation are
120 degrees and 45 degrees, respectively. Manual goniometers generate good test-retest
reliability and are the first choice tool for assessing hip ROM in the clinic. Test-retest
reliability coefficients have been shown to be above 0.90, while concurrent validity
coefficients ranged between 0.44 and 0.94 (Nussbaumer et al., 2010).
Hip MMT. Manual muscle testing was used to assess bilateral hip strength in
flexion, internal rotation, and external rotation. The client was tested in a seated position
with his back supported and pelvis stabilized by the chair. The client also placed his
arms across his chest during testing. The values of the initial and follow-up MMT are
provided in Table 1. At the initial evaluation, right hip flexion was recorded as 4/5
(good; holds test position against moderate pressure). Right hip internal rotation was
recorded as 3+/5 (fair +; holds test position against slight pressure. Right hip external
rotation was recorded as 4-/5 (good -; holds test position against slight to moderate
pressure). Left hip flexion, internal rotation, and external rotation were all recorded as 4/5 (good -; holds test position against slight to moderate pressure). MMT has
demonstrated good reliability for assessing hip muscle group strength, and is a consistent
evaluation tool (Wadsworth et al., 1987).
Numeric Pain Rating Scale. The client was asked to rate his pain intensity for
hip pain symptoms at the conclusion of a round of golf, using the Numeric Pain Rating
Scale (NPRS) (Figure 4), ranging from 0 (no pain) to 10 (worst pain imaginable).
Figure 4: Numeric Pain Rating Scale
At the initial evaluation, the client reported his pain to be 5/10 (moderate) for both his
right and left hip. Initial and follow-up pain intensity scores for hip pain symptoms are
provided in Table 1. The clinically important difference for the NPRS has been shown to
be a reduction of 2 points (Farrar et al., 2001).
Table 1. Physical Examination Key Findings:
Test or Measure
Right hip active ROM, deg
Flexion
Internal Rotation
Left hip active ROM, deg
Flexion
Internal Rotation
Right hip MMT
Flexion
Internal Rotation
External Rotation
Left hip MMT
Flexion
Internal Rotation
External Rotation
NPRS hip pain (0-10)
Right hip
Left hip
Initial Examination
Follow-up Examination (8
wk)
90
15
90
32
60
22
82
38
4/5
3+/5
4-/5
4+/5
4/5
4/5
4-/5
4-/5
4-/5
4+/5
4+/5
4+/5
5
5
1
1
Clinical Impression
Based on findings from the initial examination, the client in this case report is
appropriate for implementation of an eight-week, golf specific exercise program to
improve bilateral hip ROM and to reduce subjective symptoms. The TPI Golf Medical
and Fitness Professional who administered the initial examination also implemented the
specific exercise protocol, oversaw the progress of the client throughout the eight weeks,
and executed the follow-up examinations. The outcome of this intervention plan was
determined by an eight-week follow-up TPI screen, as well as objective measurements of
the client’s ROM of his bilateral hip flexion and internal rotation. The follow up
objective measurements also included MMT of the client’s hip flexion and internal
rotation.
Intervention (Application of Theory to Practice)
Based on the findings of the initial TPI Screen (Table 1), subsequent treatment
sessions focused on implementation of an exercise prescription intervention with
components targeting (1) bilateral hip musculature weakness and (2) decreased bilateral
hip ROM. To address these deficits, the therapeutic program consisted of ten dynamic
exercises as described in Appendix B. The ten golf specific exercises prescribed were:
(1) 25-25-25, (2) comerford hip complex, (3) flow row, (4) burpee advanced, (5) medball straight arm tornadoes, (6) deadlift with dumbbells, (7) lift-resisted rotation split
stance, (8) chop-cable resisted two arms two handles split stance, (9) two-arm cross body
latissimus dorsi stretch, and (10) hip rotation mobilization with movement. The 25-25-25
exercises provided a dynamic warm-up for the client before performing the remaining
nine exercises. The client performed all exercises three times per week, with the
guidance of a TPI Golf Medical and Fitness Professional. For weighted resistance
exercises, a 5% increase in load was applied when the client was able to perform the
workload for 2 repetitions over the desired number on two consecutive training sessions
(ACSM, 2009).
Outcomes
The client attended 24 treatment sessions over the course of 8 weeks, in addition
to the initial and follow-up examinations. Outcomes were recorded at the initial
evaluation and after completion of eight weeks of training (Table 1). At the follow-up
examination, the client’s active right hip flexion was unchanged. His right hip internal
rotation improved from 15 degrees to 32 degrees. Active ROM for left hip flexion
improved from 60 degrees to 82 degrees, and left hip internal rotation improved from 22
degrees to 38 degrees. All of the recorded MMT improved bilaterally in flexion, internal
rotation, and external rotation. Right hip flexion strength improved from 4/5 to 4+/5
(good +; holds test position against moderate to strong pressure). Right hip internal
rotation strength improved from 3+/5 to 4/5 (good; holds test position against moderate
pressure). Right hip external rotation improved from 4-/5 to 4/5. Left hip strength for
flexion, internal rotation, and external rotation all improved from 4-/5 to 4+/5. The
client’s golf handicap index was not assessed at the completion of eight weeks. The
United States Golf Association requires 20 rounds of golf to be calculated, and the client
did not participate in enough rounds of golf after the conclusion of the eight weeks of
training for a handicap index to be calculated (U.S.G.A., 2015). At the follow-up
examination, the patient reported improvement from 5/10 to 1/10 of bilateral hip pain
intensity at the completion of a single round of golf.
Discussion
This case report described how a golf specific functional assessment could be
used to prescribe and implement an exercise prescription intervention plan to improve
golf performance. At initial examination, the client’s right hip active internal rotation
was only 15 degrees. Relative right hip internal rotation during the backswing of less
than 30 degrees causes the pelvis to ascend and shift laterally to the right. Hip mobility
accounts for approximately 10% of the linear velocity produced in the downswing, and a
lateral shift reduces the amount of clubhead speed available at the start of the downswing.
Following the 8-week intervention program, the client’s right hip active internal rotation
improved to 32 degrees, an improvement of over 53%. Left hip active internal rotation
improved from 22 degrees to 38 degrees, an improvement of over 42%. The client also
demonstrated improved bilateral hip strength for flexion, internal rotation, and external
rotation. Though this study did not exam specific golf performance measurable, such as
clubhead and ball speed, a previous study by Sell et al. (2007) showed that an 8-week
training program that improved hip strength and flexibility resulted in improved clubhead
speed, ball speed, carrying distance, and total ball distance. Future studies will benefit
from a follow-up TPI functional screen to monitor any improvements in the client’s golf
fitness level and to assess clubhead speed or golf handicap index before and after 8-week
intervention program.
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http://www.usga.org/Rule-Books/Handicap-System-Manual/Handicap-Manual/
Appendix A: Titleist Performance Institute (TPI) Screen:
Assessment 1: Pelvic Tilt Test
Question: What is their starting Pelvic Tilt?
Answer: Neutral
Findings: You have a good neutral pelvic posture at set up. This is good for proper
muscle stabilization during the swing and will help transfer energy from your lower body
to your upper body.
Question: How was their Amount of Movement?
Answer: Normal Pelvic Tilt.
Findings: You can perform a standing pelvic tilt, which demonstrates good mobility in
your lumbar spine and good control of the muscles that help position the pelvis during the
golf swing. This should help you shift your pelvis into a stable position to help stabilize
the large rotary force used to fire the upper body during the golf swing.
Question: What is the quality of their movement?
Answer: Smooth Motion
Findings: You demonstrated good motor control with smooth movement when asked to
tilt your pelvis back and forth in golf posture. This is a good sign that you will be able to
control the motion of your pelvis in the golf swing.
Assessment 2: Pelvic Rotation Test
Question: How was their Pelvic Rotation without help?
Answer: Limited Bilaterally
Findings: You have difficulty rotating your lower body independent of your upper body.
This can prevent you from initiating the downswing with a proper sequence and limit the
coil between your upper and lower body.
Question: If you had to hold their shoulders - what happened?
Answer: Both Directions Improved
Findings: You have the ability to rotate your lower body independent of your upper
body, but only with someone else holding your upper body still. This means you have a
stability problem in your upper body.
Question: How was the Coordination of the Movement?
Answer: Good Rotary Motion
Findings: You have good coordinated control of the muscles that rotate your lower body
independently from your upper body. This is important for proper sequencing in the golf
swing.
Appendix A: Titleist Performance Institute (TPI) Screen (Continued):
Assessment 3: Torso Rotation Test
Question: How was their Torso Rotation without help?
Answer: Limited Bilateral
Findings: You have difficulty rotating your upper body independent of your lower body.
This can lead to excessive lateral sway during the backswing, loss of trunk posture during
the backswing, and faulty swing planes. Plus, it can cause your hips to outrace your trunk
during the downswing and cause you to come out of your posture.
Question: If you had to hold their hips - what happened?
Answer: Both Directions Improved
Findings: You are good at stabilizing your lower body and rotating your upper body
independently in both directions. This is important for creating power and maintaining a
good spine angle between your upper and lower body during the swing.
Assessment 4: Overhead Deep Squat Test
Question: How was their Overhead Deep Squat?
Answer: Arms Crossed Full Deep Squat
Findings: It is tough for you to perform a full deep squat while keeping your heels on the
ground and a club over your head. But when you lower the club you can now perform a
full deep squat. This is due to restrictions in your upper spine and/or shoulder flexion.
This is a key indicator for your ability to maintain good posture at the top of your
backswing. Because of this limited range of motion, maintaining a flexed posture from
the waist down while elevating your arms during the backswing can be difficult.
Question: How was their Half-Kneeling Dorsiflexion Test?
Answer: Good Dorsiflexion Bilateral
Findings: You have good flexibility in both calves. If there is any limitation in your
squat mechanics it is probably due to your core muscles not stabilizing your pelvis
properly during the squat. To maintain or develop a better squat, focus on core
stabilization exercises while trying to perform a good deep squat.
Question: How was their Weight Distribution?
Answer: Their weight is evenly distributed during the squat.
Findings: You do a great job of evenly distributing your weight between your right and
left side during routine movements, like performing a squat.
Assessment 5: Toe Touch Test
Question: How was the Bilateral Toe Touch Test?
Answer: Can't Touch Toes
Findings: It is difficult for you to bend over and touch your toes with your knees locked.
This can be due to a bilateral hip restriction or inflexibility in your lumbar spine, calves
and hamstrings. These limitations can make it difficult to set up in a good golf posture
and maintain that posture throughout you swing. Hip restrictions can make sitting into
your right hip on the backswing and posting into your left hip during the downswing
seem impossible. They can also lead to lower back and hip pain during golf.
Question: How was the Unilateral Toe Touch Test?
Answer: Both Limited
Findings: It is difficult for you to bend over and touch your toes with your knees locked.
This can be due to a bilateral hip restriction or inflexibility in your lumbar spine, calves
and hamstrings. These limitations can make it difficult to set up in a good golf posture
and maintain that posture throughout you swing. Hip restrictions can make sitting into
your right hip on the backswing and posting into your left hip during the downswing
seem impossible. They can also lead to lower back and hip pain during golf.
Assessment 6: 90/90 Test
Question: How far was their Standing External Rotation on the Right?
Answer: Greater than Spine Angle
Findings: The total external rotation in your right shoulder is over 90 degrees while
standing tall. The average range of motion for players on the PGA Tour is over 90
degrees. You have good external rotation in your right shoulder, which should allow you
to set the club and rotate your right arm into any position that you want during the
backswing.
Question: What was the difference in Golf Posture on the Right?
Answer: Same as standing
Findings: You maintain the degree of external rotation in your right shoulder when
getting into your golf posture. Some people tend to lose their total range of motion in
their shoulder due to lack of stability in their shoulder blades when bending from the
waist.
Question: How far was their Standing External Rotation on the Left?
Answer: Less than Spine Angle
Findings: The total external rotation in your right shoulder is less than 90 degrees while
standing tall. The average range of motion for players on the PGA Tour is over 90
degrees. Since your range of motion is limited, you might have some difficulty in
properly rotating your right arm during the backswing. Related swing faults could be
flying right elbow, getting trapped or stuck on the downswing, loss of posture or an overthe-top swing plane.
Question: What was the difference in Golf Posture on the Left?
Answer: Same as standing
Findings: You maintain the degree of external rotation in your right shoulder when
getting into your golf posture. Some people tend to lose their total range of motion in
their shoulder due to lack of stability in their shoulder blades when bending from the
waist.
Assessment 7: Single Leg Balance Question: How many seconds with Eyes Closed on the Right?
Answer: 6-10 seconds
Findings: We tested your ability to stand on your right leg only with your eyes closed.
This was testing your overall balance on the right side of your body. You could only
stand for 6-10 seconds before having to open your eyes. Over 16 seconds is considered
good balance for the elite golfer. This limited balance on your right side can limit your
ability to load into your right side or cause you to lose stability during the backswing.
Question: How many seconds with Eyes Closed on the Left?
Answer: 0-5 seconds
Findings: We tested your ability to stand on your left leg only with your eyes closed.
This was testing your overall balance on the left side of your body. You could only stand
for less than 5 seconds before having to open your eyes. Over 16 seconds is considered
good balance for the elite golfer. This limited balance on your left side can limit your
ability to post into your left side or cause you to avoid your left side during the
downswing.
Assessment 8: The Latissimus Dorsi Test (Shoulder Flexion Test)
Question: How many degrees on the Right?
Answer: Covers the Nose
Findings: You have approximately 120 degrees of flexion in your right shoulder. Normal
range of motion on the PGA Tour is over 170 degrees. Any limitation in the right lat
muscle or shoulder girdle itself can affect your ability to rotate your trunk around your
lower body past impact and it can cause your right arm to be restricted through your
finish.
Question: How many degrees on the Left?
Answer: Covers the Nose
Findings: You have approximately 120 degrees of flexion in your left shoulder. Normal
range of motion on the PGA Tour is over 170 degrees. Tightness in this area can lead to
loss of spinal posture as the arms are elevated during the backswing. Plus, this can restrict
your overall shoulder turn during the backswing.
Assessment 9: Lower Quarter Rotation Test
Question: How was their Backswing rotation?
Answer: Limited Rotation on the Right Leg
Findings: You have limited internal rotation on the right leg. Any reduction in internal
rotation on the right leg can lead to an inability to rotate properly without losing posture
on the backswing.
Question: How was their Downswing Rotation?
Answer: Limited Rotation on Left Leg
Findings: You have limited internal rotation on the left leg. Any reduction in internal
rotation on the left leg can lead to an inability to rotate properly on the downswing
without coming out of posture through impact.
Assessment 10: Seated Trunk Rotation Test
Question: How far do they rotate Right?
Answer: Equal to 45 degrees
Findings: You have limited mobility rotating you thoracic spine to the right. Normal
right rotation is over 45 degrees on the PGA Tour and you had exactly 45 degrees. This
may limit you ability to get a full shoulder turn and maintain a good stable posture during
your backswing.
Question: How far do they rotate Left?
Answer: Greater than 45 degrees
Findings: You have good mobility rotating you thoracic spine to the left. Normal left
rotation is over 45 degrees on the PGA Tour and you had over 45 degrees. This should
help you get a full shoulder turn through impact and maintain a good stable posture
during your swing.
Assessment 11: Bridge with Leg Extension Test
Question: What happened when their Right Leg was down?
Answer: Right Glute was Normal
Findings: You have good strength and stability in your right glute muscles. This will
help you maintain good lower body stability in the backswing and power on the
downswing.
Question: What happened when their Left Leg was down?
Answer: Left Glute was Normal
Findings: You have good strength and stability in your glute max muscles on the left.
This will help you maintain good pelvic posture and lower body stability during the
downswing.
Assessment 12: Cervical Rotation Test
Question: How is their left cervical rotation?
Answer: Can't rotate to Mid-Clavicle
Findings: You have limited left rotation in your neck. Normal range of motion is over 70
degrees. This can limit your ability to fully rotate your shoulders during the backswing
while maintaining a stable head and body posture.
Question: How is their right cervical rotation?
Answer: Can't rotate to Mid-Clavicle
Findings: You have limited right rotation in your neck. Normal range of motion is over
70 degrees. This can limit your ability to maintain your posture during the downswing
and fully rotate your shoulders through impact.
Assessment 13: Forearm Rotation Test
Question: How much total Forearm Pronation (Palms Rotating Down) do they have?
Answer: Normal (Greater than 80 degrees)
Findings: You have normal proation (rotating palms down) on both forearms. This will
help you set and release the club properly throughout the swing.
Question: How much total Forearm Supination (Palms Rotating Up) do they have?
Answer: Normal (Greater than 80 degrees)
Findings: You have normal supination (rotating palms up) on both forearms. This will
help you set and release the club properly throughout the swing.
Assessment 14: Wrist Hinge Test
Question: How much total Wrist Hinge Up (Radial Deviation) do they have?
Answer: Normal Bilaterally
Findings: You have good hinge up (radial deviation) in both wrists. This will help you
set the club properly during the swing.
Question: How much total Wrist Hinge Down (Ulnar Deviation) do they have?
Answer: Normal Bilaterally
Findings: You have good hinge down (ulnar deviation) in both wrists. This will help you
release the club properly during the swing.
Assessment 15: Wrist Flexion Test
Question: How much total Wrist Flexion (Bowing) do they have?
Answer: Normal (60 degree or Greater)
Findings: You have normal flexion (bowing) in both wrists. This will help you set and
release the club properly throughout the swing.
Assessment 16: Wrist Extension Test
Question: How much total wrist extension (Cupping) do they have?
Answer: Normal (60 degree or Greater)
Findings: You have normal extension (cupping) in both wrists. This will help you set
and release the club properly throughout the swing.
Appendix B: Specific Exercises:
10 Exercises Duration: 45 minutes – 1 hour
1) 25-25-25 3 sets
Description:
Perform 25 jumping jacks, 25 seal jacks and 25 sagittal-plane swings.
Resistance: 0
Instructions: Switch to the next exercise after each set - jumping jacks first, seal jacks
second and sagittal plane swings last.
Set
Reps
Sec. / Rep
Sec. / Rest
1
25
1
5
2
25
1
5
3
25
1
60
Appendix B: Specific Exercises (Continued):
2) Comerford Hip Complex
Description:
Lie on your side with your knees bent and feet on top of each other. Keeping your feet in
contact with each other, try to lift your top knee up as far as possible.
Next, keep your knees together and raise the top foot away from the bottom foot and
slowly return to starting position. This is simply a clam shell as described above, but in
reverse.
Next, split your knees apart and perform the reverse clamshell while keeping your knees
approximately six inches apart during all leg movements.
Finally, with knees split apart six inches, take top leg and move it backwards (extend)
until the upper leg (femur) is in line with the spine and perform reverse clamshells.
Repeat on opposite side.
Set
Reps
Sec. / Rep
Sec. / Rest
1
1
90
30
3) Flow Row
Description:
Standing on your lead leg facing a cable cross machine and hold onto a cable cross
handle with your trailside hand. Slow and controlled, rotate your entire trunk clockwise
(away from the resistance) and perform a row at the end of the movement. Return to the
starting position. Repeat on opposite leg.
Instructions: Repeat in opposite direction
Set
Reps
Sec. / Rep
Sec. / Rest
1
8
6
30
2
8
6
30
4) Burpee Advanced
Description:
Begin in a standing position. Drop into a squat position with your hands on the ground.
Next, extend your feet back in one quick motion to assume the front plank position. Now,
return to the squat position in one quick motion. Finally, return to standing position and
jump in the air as high as possible. Repeat
Set
Reps
Sec. / Rep
Sec. / Rest
1
8
8
60
2
8
8
60
5) Med-Ball Straight Arm Tornadoes
Description:
Holding a med-ball out in front of your chest with your arms extended, try to rotate the
ball back and forth as fast as possible.
Set
Reps
Sec. / Rep
Sec. / Rest
1
10
3
30
2
10
3
60
6) Deadlift with Dumbbells
Description:
Place the feet in a symmetrical stance approximately hip width apart and the head neutral
and hold a dumbbell in each hand (resting against your thighs). Begin by taking the hips
straight back with a slight knee bend while the shins remain vertical. Extend back until a
quality and appropriate range of hip hinge is reached. Return to the starting position the
exact same way using the hips to regain standing position. Be sure the head and neck are
neutral and there is no rounding of the back.
Set
Reps
Sec. / Rep
Sec. / Rest
1
12
5
30
2
12
5
30
3
12
5
60
7) Lift - Resisted Rotation Split Stance
Description:
Attach one end of the tubing to a low point attachment. With hands separated and palms
facing down grab the black foam of the FMT. Get into a split or lunge stance with your
foot farthest from the anchor point forward. Both knees should be flexed. Hold hips
directly under the trunk and spine erect with shoulders back. Pull up the tubing across
the chest while keeping it close. Trunk should rotate and follow your hands throughout
the exercise. Lower body should remain stable.
The tubing should come across the body from shoulder to opposite hip, palms facing
down. Tubing should be in line with closest arm. For more resistance, slide farther away
from the point of attachment. Before starting your exercise, please make sure the point of
attachment for the tubing is secure.
Set
Reps
Sec. / Rep
Sec. / Rest
1
12
5
15
2
12
5
30
8) Chop - Cable Resisted Two Arms Two Handles Split Stance
Description:
Set both handles of the cable cross to the high position. Get into a split stance with your
down knee away from the cable cross. Grab both handles with both hands and keep your
posture as tall as possible. Perform a chop diagonally across your body keeping your
hands close to your chest throughout the movement. Slowly return to the starting
position. Repeat the appropriate number of sets and reps.
Set
Reps
Sec. / Rep
Sec. / Rest
1
12
8
30
2
12
8
30
9) Two-Arm Cross Body Latissimus dorsi Stretch
Description:
Using a stretching pole, golf cart or other object for support, get in golf posture and place
one arm on the object, then with the opposing arm stretch across your body applying
pressure on the object to create a stretch in the latissimus dorsi and shoulder. This is
good body prep for golfers that lose their posture due to tightness in the latissimus dorsi
and shoulders.
Instructions: This is a great stretch for those golfers that lose their posture during their
swing or have difficulty with the correct pivot motion.
Set
1
2
Reps
5
5
Sec. / Rep
5
5
Sec. / Rest
30
30
10) Hip Rotation Mobilization with Movement
Description:
Set up a mobilization belt to wrap around the client’s proximal thigh and clinician’s hips.
Clinician sits backwards into hip, providing a sustained grade I distraction. With
sustained distraction, the client actively moves into the full available hip internal and
external ROM.
Set
1
2
Reps
10
10
Sec. / Rep
5
5
Sec. / Rest
30
30

Exercises for Improving Hip Rotation USE OF GOLF SPECIFIC

Transcription

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