Movement and Golf - Ohio Physical Therapy Association

4/13/2016
Movement and Golf
An Overview to Minimize Dysfunction and Maximize Performance
Ohio Physical Therapy Association
Annual Conference 4/23/16
OSU Sports Medicine
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Introduction:
Our Team
• Mike Martin, PT, MPT, OCS, CGFI-M2
• Erik Hemenway, AT, PTA, CGFI-J2
• Anthony Ganim, PT, MPT, OCS, CGFI
• Kyle Steinbauer, PT, DPT, OCS, CSCS, CGFI
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Disclosures
 The individual presenters for this course and The
Ohio State University Wexner Medical Center, Sports
Medicine, have no conflicts or disclosures to report.
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Objectives
 Learn basic components and functional requirements
of the golf swing
 Understand common examples of dysfunctional
posture or movement patterns involved with golf
 Highlight common changes across the lifespan, and
how they contribute to injury or poor performance
 Identify techniques for assessing dysfunction and
providing intervention strategies to correct
 Review recommendations for a successful,
comprehensive golf medicine and performance
program
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Introduction
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Background/Etiology
 2015: 25 million amateur golfers in U.S.
 National Golf Foundation
 Statista.com: 26.02 million reported golfing in the past 12 months (2015)
 Injury Prevalence:
 Up to 40% of all amateur golfers have pain/injury
 33-37% Low Back Pain
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Background
 Sources of potential injury:
 The golf swing
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Poor mechanics
Poor “lie” or ground conditions
Overuse
Predisposing physical condition prohibiting safe swing
Improper equipment
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Background
 Non-swing sources of injury:
 Walking
 No cart: 5.5-6.5 miles over 18 holes
 Cart path only: 2.5-3.5 miles over 18 holes
 Pushing cart or carrying bag
 Uneven surfaces, hills, thick grass
 Bending over to pick up ball
 Accidents/Trauma
 The golfer who is injured
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Background
 Common injury/pain locations
 Low back
 Elbow
 Lateral elbow – lead arm
 Medial elbow – trailing arm
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Thoracic Spine
Shoulder
Hip
Foot, knee, other
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Golf Swing Basics
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The Golf Swing
 What do most golfers desire in their swing?
 More Power
 Better Consistency
 How do we achieve this?
 Understand typical golf swing posture and movement
 Utilize the Kinematic Sequence
 Development of swing efficiency of movement and
power
 Assess biomechanics of the patient
Why Golf Biomechanics?
 Studies have tried to characterize the “ideal” golf
swing
 Many different teaching and assessment techniques
out in the market
 Review of previous literature findings from clinical
standpoint:
1. Understanding efficient movement principles of the
golf swing will help a practitioner express advice and
corrections on a clients swing
2. Corrections should lead to a reduction of injury
3. Biomechanics work has role in the development of
accuracy and distance in the golf shot
Source: Hume et al, 2005
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Phases of the Golf Swing
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Setup (Address) Posture
 Address Posture Basics
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Golfer starts in relaxed forward bent posture
Cervical and Thoracic Spine in forward bent position
Lumbar spine in neutral positioning
Trunk
 Flexion ~ 45 degrees
 Hip
 Flexion ~ 15-30 degrees
 Knee
 Flexion ~ 15-20 degrees
Source: Rose et al. 2016 & Hume et al, 2005
Takeaway/Backswing
 Purpose:
 Positioning of the golfer in preparation for an effective
and powerful downswing
 Period of takeaway from the ball after the address
 Movement Basics
 Slowest Portion of the golf swing
 Multi-plane approach to muscle activation and
movement
 Primarily torso and lower body rotation focus
 Good Mobility in neck, trunk, pelvis, hips (Rose et al, 2015).
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Downswing/Acceleration
 Quickest Portion of the Swing
 Divided into sub phases:
1. Forward swing phase, which initiates the downward
motion of the club
2. Acceleration phase, which accelerates the club
downward.
 Movement Basics:
 Gluteus maximus for power generation
 Downswing hinges on what the glute max can do
 Glute max has over 50% activation all the way to the
early stages of the follow through swing
 Gluteus medius for lateral stabilization
Source: Hume et al, 2005
Downswing/Acceleration
Muscles with the most
activation during the
downswing
 Gluteus Maximus
 Biceps Femoris
 Vastus Lateralis
 Pectoralis Major
 Scapular Stabilizers
(Rhomboid, Serratus Ant.)
 Rotator Cuff Musculature
(infraspinatus and
subscapularis)
Source: Rose et al. 2015
Impact/Follow-Through
 Point of the swing where most deceleration occurs
 Pelvis and Thoracic Rotation are decelerating speed but
have extensive movement into the follow through
Source: Cole, 2015
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Impact/Follow-Through
 Following impact, the upper thorax turns through at least
120° and the golfer concludes with their vertebral column
in a hyper-extended position
 Trail shoulder (right in right-handed golfers) pointing
towards the target, and their hands positioned high above
their head. This posture is commonly referred to as the
‘reverse C’ position
Source: Cole, 2015
Kinematic Sequence
 Biomechanics and movement are only one component of
the efficient golf swing
 TPI Philosophy:
 “We don’t believe there is one way to swing a club.
We believe there are an infinite number of ways to
swing a club. But we do believe there is one efficient
way for everyone to swing a club and it is based on
what they can physically do”
 Kinematic Sequence
 True measure of an efficient golf swing
 Correlates with the mechanical motion of the body
 Use of 3D to measure energy transfer
Source: TPI Level 1 Manual
The Kinematic Sequence
Acceleration
The Downswing Phase
1. Pelvis accelerates and peaks at a lower speed than
other segment, and then decelerates rapidly
2. Thorax accelerate to a higher speed than the
pelvis, and the decelerates rapidly
3. Lead Upper Arm accelerates to a higher speed than
the thorax and then decelerates rapidly.
4. Club continues accelerating reaching maximum
speed at impact.
Source: TPI Level 1 Manual
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The Kinematic Sequence
Energy Initiation/Transfer
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The Kinematic Sequence
The Kinematic Sequence
Key Points
1. The sequence should be consistent despite the swing
style
2. Each segment of the body builds on the previous
segment, increasing speed up the chain
3. Each segment of the chain slows down as the next
segment continues to accelerate
4. Sequence is the key to consistency; energy transfer is
the key to power
3-D analysis determines swing efficiency and/or
limitations; the physical screen determines why
those inefficiencies may be occurring
Source: TPI Level 1, 2013
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Common Dysfunctional
Swing Patterns
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Swing “Faults”
 Swing Faults – Specific swing characteristics or patterns
which contribute to both poor or inconsistent performance
and pain or injury
 Every golfer has characteristic swing patterns that are
either a result of or lead to physical limitation or
dysfunction
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Categorizing Swing Characteristics
 Characteristics relating to posture
 Characteristics relating to lower body movement
 Upper body characteristics and injuries
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Swing Characteristics Relating to Posture
 Posture at Address
 Neutral Posture
 “C” Posture
 “S” Posture
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Posture at Address
 “C” posture
 Typically hypomobile thoracic spine
 Poor scapulothoracic stability
 Hypomobile lumbopelvic and hip regions
 Inability to reach full excursion during backswing
 Will lead to other swing characteristics and potential
contributors to injury
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Posture at Address
 “S” Posture
 Inhibited deep abdominal mm.
 Decreased lumbopelvic stability
 Increased compression at lumbar spine
 Inability to maintain posture through swing
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Posture During and Through the Backswing
 Loss of Posture
 Reverse Spine
 Flat Shoulder Plane
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Loss of Posture
 “Any significant alteration from your body’s original setup
angles during the golf swing.” - TPI
 Decreased lower body mobility
 Decreased trunk/core and hip stability
 Decreased shoulder, torso or lat mobility
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Reverse Spine
 Excessive backward upper body bend at the top of the
golf swing
 #1 Cause of LBP in amateur golfers!
 Decreased hip mobility
 Right hip IR
 Decreased torso, spine, shoulder, lat mobility
 Decreased trunk/core and hip stability
 Increased lumbar paraspinal tension and inhibited
deep abdominals
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Flat Shoulder Plane
 A change in the plane of the shoulders when turning to
the top of the backswing
 Shoulder plane perpendicular to spine at address but
turns to more horizontal plane at top of backswing
 Same physical deficits as loss of posture and reverse
spine
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Lower Body Movement Characteristics
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Sway
 Any excessive or significant lower body movement away
from the target during the backswing
 Limited rear hip IR
 Decreased R hip stability/decreased gluteal strength
 Decreased torso, shoulder, lat mobility
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Slide
 Any excessive lower body movement toward the target
during the golf swing
 Decreased lead hip IR
 Decreased lead hip stability
 Decreased torso, shoulder, lat mobility (gluteus
medius)
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General Upper Body Characteristics
 “The Ultimate Cheater”
 Body will compensate in any way possible to
complete a task
 Lack of lower body mobility or stability leads to
decreased power output
 Lack of upper body mobility leads to decreased swing
excursion
 Body will attempt to compensate through excessive
arm/wrist/hand movement or activation
 Chicken winging
 Casting
 Scooping
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Upper Body Swing Characteristics
 Difficult for untrained person to assess without video
analysis
 In PT eval, look for keys through pt report, pain
assessment (location, quality, etc.) and objective
evaluation
 Elbow injuries
 Shoulder injuries
 Wrist/hand injuries
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Considerations Across
the Lifespan
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Deficits Across the Lifespan- Juniors
Common Injuries with Junior Players
 Golfer’s Elbow
 Low Back Pain
 Bone Injuries
 Shoulder Pain
 Sunburn
Alternative Issues
 Deficient Training Practices
 Long Term Athletic Development
Long Term Athletic Development
(LTAD)
First coined by Istvan Balyi in 1998
Key Focus of training is on performing age-appropriate
drills to maximize potential of training
LTAD uses foundational approach found in 10 year rule
“Research has concluded that it takes eight to twelve years
of training for a talented athlete to reach elite levels This is
called the ten-year or 10,000 hour rule. For athletes,
coaches and parents, this translates as slightly more than
three hours of practice daily for ten years”
Source: Balyi, 1998
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Long Term Athletic Development
(LTAD)
 5 Stage Model for Late Specialization
1. The Fundamental Stage
 6-10 year old Males and Females
2. The Training to Train Stage
 Males 10-14; Females 10-13
3. Training to Compete Stage
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Males 14-18; Females 13-17
4. Training to Win Stage
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Males 18+; Female 17+
5. The Retirement/Retraining Stage
Source: Balyi, 1998
Deficits Across the Lifespan –
The Senior Golfer
 This is the “typical” golfer
 Because this may be the activity to motivate your patient,
it is an avenue to incorporate activity into their life
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Physical Changes for the Senior Golfer
 Declining
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Strength
Flexibility
Coordination
Balance
 How much of this is inevitable and how much can be
slowed/stopped
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Strength in the Senior Golfer
 Loss of strength due to loss of
 Size (atrophy)
 Number (hypoplasia)
 Strength loss may be inevitable, but it can be slowed
 Aerobic and resistance training
 Also consider the neuromuscular impact
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Balance in the Senior Golfer
 Decreased average SLS as people age
 By decade of life
 60’s Male: 28.7 sec, Female: 25.1 sec
 70’s Male: 18.3 sec, Female: 11.3 sec
 80’s Male: 5.6 sec, Female: 7.4 sec
 Clear for vertigo, falls, dizziness, other vestibular
disorders
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Flexibility in the Senior Golfer
 Loss of flexibility due to physiologic factors
 Decreased elasticity of collagen
 Increase connective tissue to lean muscle mass
 Due to lifestyle changes
 Decreased activity levels
 Consider the hips, spine, ankles and shoulders
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Cardiovascular decline in the Senior Golfer
 Decreased maximal HR, HR response
 Results in decreased exercise capacity
 Golf is a power sport built on endurance
 Must address both
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Implications for age-related losses
 Typical postural deficits
 Forward Head
 Rounded Shoulders
 Increased Kyphosis
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So what?
 Repetitive swings with a loss of posture, decreased
flexibility, decreased physical condition, decreased
balance
 Lead to increased use of compensations and swing
faults
 Increasing the chances of developing overuse injuries
 Creates a domino effect
 increased pain,
 decreased activity
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Exercise focus for the Senior Golfer
 Flexibility/Mobility
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Hip joint mobility – int rot, ext rot
Hip flexor tightness
Trunk – T-spine extension and rotation
Shoulder – capsular tightness, pec tightness
Cervical – extension, retraction, rotation mobility
 Motivation is key to compliance
 Get some early wins to show the value
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Exercise focus for the Senior Golfer
 Strengthening and Stability
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Focus on golf specific movements
Rotational stability exercises
Core control and isolation
Scapular strength and control
 Golf is a repeated unilateral sport
 Make sure to train in both directions to avoid muscle
imbalances and asymmetries
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Special Considerations for the Senior Golfer
 Total Joint Replacement – THA and TKA
 Be aware of surgical precautions and surgeon
precautions
 Return to golf estimates
 THA – typically 3-6 months post-op
 TKA – More variable due to rotational forces through
the knee
 Incorporate trunk and hip rotation ex’s early and
progress intensity and weight bearing as appropriate
 TSA/RTSA
 Variable – 2-8+ months (longer, if at all, for RTSA)
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Special Considerations for the Senior Golfer
 Osteoporosis
 Common in hips, spine and wrists
 Be cautious with high velocity rotational activities
 May need to modify swing
 Consider vertebral compression fractures in the
thoracic spine with postural correction or high stress
positions
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Special Considerations for the Senior Golfer
 Need for a high quality warm up
 Focus on short, efficient warm up to improve
compliance
 Use of off season to prepare for next year
 Increased chance of co-morbidities
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Evaluation of the Golfer
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Evaluation
 Golfer most likely will not be ready day 1 for golf
evaluation/screening
 Need to clear initial/underlying injury first!!
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Subjective
 General History
 Gives PT a good idea on which other health care
professions may need to be consulted
 ie: nutritionist, sports psychologist, physician,
swing coach
 Any pertinent medical history
 Injury/Surgical History
 Helps PT identify possible areas of impairment
 Can also predict swing faults/characteristics
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Subjective
 Golf Ability History
 Allows PT to determine level of skill
 Could predict overuse vs deconditioning as cause
 Areas of strength and weakness
 ie: ball striking, distance, pain at end of round, pain
with certain swing or shot
 Pain provocation – where during the round/swing is
there pain
 Goal Development
 What does the golfer want to get out of treatment?
 Play pain-free? Distance? Consistency? Lower
scoring?
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Objective
 Recommended equipment
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Mid iron (5-7)
Alignment or doll rods
½ foam roll
Airex Mat
 Evaluation algorithms – you choose!
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Objective
 Based on Mobility/Stability Model
“The body works in an alternating pattern of stable
segments connected by mobile joints. If this pattern is
altered dysfunction and compensation will occur.”
–Gray Cook
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Mobility/Stability Model
 Mobility
 The ability to produce a desired movement
 Stability
 The ability to resist an undesired movement
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Objective
 Postural assessment
 “Down the line”
 Quiet posture and golf posture
 Lower extremity positioning, pelvic positioning, spinal alignment,
shoulder positioning, head positioning, hand positioning, distance from
golf ball
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Objective
 S Posture
 Lower Crossed Syndrome
 Tight Muscles- hip flexors, back (erector spinae), TFL, and
quadratus lumborum
 Weak Muscles- gluteus maximus, rectus abdominis, and
gluteus medius
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Objective
 C Posture
 Upper Crossed Syndrome
 Tight Muscles- upper trapezius, levator scapulae,
suboccipitals, SCM, and pectoralis major/minor
 Weak Muscles- lower/mid trapezius, deep neck flexors,
serratus anterior
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Objective
 Postural Assessment
 Frontal/Coronal View
 Looking for body symmetry, hand position, lower extremity
alignment
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Objective
 Foot (stability)
 Single leg balance
 Compare bilaterally
 Stable and unstable surface
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Objective
 Ankle (mobility)
 Overhead Deep Squat
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Objective
 Ankle (mobility)
 Arms Down Full Deep Squat
 If patient fails overhead deep squat
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Objective
 Ankle (mobility)
 Half Kneeling Dorsiflexion test or Anterior Tibial
Translation test
 If patient fails the arms down deep full squat
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Objective
 Knee (stability)
 Squat (double leg and single leg)
 Lateral lunge
 looking at hip/knee mechanics and ability
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Objective
 Hip (mobility)
 Overhead Deep Squat
 Lower Quarter rotation
 Looking at total lower extremity internal/external rotation
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Objective
 Pelvis/Lumbar Spine (stability)
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Front Plank- abdominals
Side Plan- oblique and hip abductors
Bridging- double and single leg
Pelvic tilting in golf posture
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Objective
 Thoracic Spine (mobility)
 Seated trunk mobility test
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Objective
 Scapula (stability)
 Lift reach and roll test
 Push-up plus test
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Objective
 Cervical Spine (mobility)
 Cervical Rotation (looking for >70dgs)
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Objective
 Shoulder (mobility)
 Shoulder 90/90 ER in standing position
 Shoulder 90/90 ER in golf posture
 Looking for greater than 90 degrees in both postures
 Lat Length
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Objective
 Elbow (stability), Wrist (mobility), Hand (stability)
 Active Radial/Ulnar Deviation
 Active Wrist Extension/Flexion
 Active wrist Pronation/Supination
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Objective
 Disassociation from lower body to upper body
 Golfer should be able to independently move hips/pelvis
while keeping upper body quite
 If golfer is unable to do so, provide manual stabilization at
the golfer’s shoulders to assess if it can be done
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Objective
 Disassociation from upper body to lower body
 While keeping the lower body “quiet”, turn the shoulders
and thoracic spine
 If golfer cannot do this, provide manual stabilization at the
hips to asses if golfer is able to improve ease of
disassociation
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Treating the Injured Golfer
General Treatment Concepts
 Be the PT first
 Focus on the Mobility-Stability Model
 Give the golfer ownership in what he/she desires
from the golf swing
 Include any swing coach/instructor as needed
 Consider change if the body can’t physically meet the
swing needs
 Fully understand when/where the pain occurs within
the context of golf
 During the round
 During the swing
 With specific clubs
General Session Flow
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Active Warm-up
Manual Interventions
Active ROM
Muscle activation as needed
Strengthening in newly-gained ROM
Functional exercise/multi-segmental exercises
Sport-specific exercises and drills
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General Treatment Concepts
 In golf medicine, the gluteals are the priority.
 Core/lumbopelvic stability is a must.
 The ability to dissociate the upper and lower bodies
is integral.
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“Non-Negotiables”
 Gluteal/bridge progression
 Hip Hinge
 Golf posture exercises
 Other dissociation exercises
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Comprehensive Golf
Medicine and
Performance Programs
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It IS a Team Game
Medical
Nutrition
Mental
Golfer
Technical
Fitness
Additional References
 Balyi I. Sport System Building and Long-term Athlete Development in British Columbia.
Canada: SportsMed BC; 2001.
 Becker L, Manske R (Eds.). Management of the Golfing Athlete Throughout the
Lifespan. Zionsville, Indiana. Sports Physical Therapy Section.
 Cole MH, Grisham PN. The biomechanics of the modern golf swing: implications for
lower back injuries. Sports Med (2016) 46:339–351.
 Cook G. Movement. Lotus Publisher; 2011.
 Gosheger G, Liem D, Ludwig K, et al. Injuries and overuse syndromes in golf. Am J
Sports Med. 2003;31(3):438-443.
 Hume P, et al. The Role of Biomechanics in Maximizing Distance and Accuracy of Golf
Shots. Sports Med (2005) 35: 429-449.
 Rose G. Titleist Performance Institute Level 1 Manual. Oceanside, CA: Titleist
Performance Institute; 2006.
 Rose G, Voight M. Titleist Performance Institute Level 2 Medical Manual. Oceanside,
CA: Titleist Performance Institute; 2012.
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