Golf Performance Comprehensive Evaluation and Exam: Case study
This week, we are going to review a case with a BCC golfer who came in looking for improvements to mobility and power in his golf swing. He was also dealing with persistent neck pain with radiating symptoms into the arm. We will discuss the initial evaluation and the key findings, how they manifest themselves in the golf swing, and the path we took to address the physical and biomechanical limitations and how they are correlated with the analysis of his golf swing.
Golfer day one comprehensive evaluation.
The initial evaluation is key for understanding what we need to do to achieve the golfers’ goals. We need to find areas of missing mobility, missing stability, altered motor control, areas of limited strength, painful and positive orthopedic testing, and examine what the golfers’ swing looks like and how that is associated with the previous findings. In other words, we search to understand their movement capabilities AND how they swing. With this, we can then determine how the issues in their swing relate to the limitations in how they move. We can also then understand how this might be creating pain now and into the future. The depth and detail of this initial exam is truly unique and one of a kind in the Nashville area.
We can break down this initial golf evaluation into 5 sections: top tier or global movement screening, golf specific movement screening, detailed joint assessment, orthopedic and functional movement testing, and golf swing evaluation. Let’s take a closer look at each with our patient.
Section 1: Global movement screening
Global movement screening helps us evaluate how the golfer creates movement with multiple joints to achieve a goal. We evaluate the integration of mobility and motor control in the creation of movement patterns. Overall, we never just want to make small changes at the individual joint level without having the changes impact the overall movement pattern. So, we evaluate the pattern, and if there are limitations, we break it down into its individual joint components to find the issues (section 3: detailed joint assessment). We can then target specific joints to evaluate in section 3 to find the exact areas to work on before re-integrating these micro changes back into the overall movement pattern (the end goal).
Here are the main limitations that we found in this golfer for this testing…
1. Multi-segmental rotation limited bilaterally
a. This assesses for the ability to create rotation throughout the body, from the ankles all the way up to the thoracic spine.
2. Upper extremity flexion, abduction, and external rotation.
a. This assesses for ability at the entire shoulder complex to cooperate and create the desired movement.
3. Cervical rotation bilaterally.
a. This assesses for the ability to rotate the neck without limitation.
Section 2: Golf specific global movement screening
This is similar to section 1, but specific to golf movements. We use Titleist Performance Institutes (TPI) golf screen to do this. Again, we are assessing for movement patterns. The screening process tells us if we need to take a closer look at the specific segments and areas involved, and after correcting the different regions with a trial of care, we can retest the whole movement pattern. Changing how we create movement patterns (and the capacity to create the swing) is again the goal of care. Here are a few of the big findings of the TPI exam with this patient.
1. The lat test.
a. This assesses for overhead mobility and everything required to get there.
2. Shoulder 90/90 test.
a. This assesses for shoulder external rotation and differentiates between general external rotation capacity Vs. external rotation in golf posture.
3. Lower quarter rotation test.
a. This is similar to our multi-segmental rotation test, but specific to the pelvis and down.
4. Trunk rotation test.
a. This assesses for general rotation ability in the trunk.
5. Bridge with leg extension test
a. This assesses for the ability to use the glute muscles when needed and the endurance capability.
Section 3: Detailed joint assessment
This is where we really dive into the detailed assessment. We have our global motor and movement patterns that helped indicate where we need to look closer and gives us a comparison to measure future change to, but now we need too critically look at all the components that made up those movements. With our joint specific testing, here were the key findings.
1. Hip internal rotation missing bilaterally, 20 degrees right and 15 degrees left.
a. We want to achieve at least 30 degrees of internal rotation in the hips. This is especially important for the golf swing in both the backswing and the downswing.
2. Shoulder internal rotation missing bilaterally, 20 degrees right and 30 degrees left.
a. Shoulder internal rotation is important for the golf swing, especially the front side shoulder while moving into the backswing. Ideally, we want 60-70 degrees of internal rotation at the shoulder.
3. Shoulder external rotation missing on the bilaterally, 80 degrees.
a. Shoulder external rotation is especially important in the backside shoulder for the backswing position. We ideally want at least 90 degrees here.
4. Ober’s test positive bilaterally.
a. This test assesses for the positioning of the pelvis in the sagittal plane. When we have positive findings that correlate with loss in other hip ranges of motion (like internal rotation), then we can assume anterior orientation at the pelvis. Ideally this test should be negative on both sides.
5. Lumbar locked limited bilaterally, 20 degrees.
a. This is a more precise way of testing thoracic rotation, a crucial component of the golf swing. We would ideally have 45 degrees in both directions. The ability to rotate the thoracic spine is evaluated in the multi-segmental rotation test in section 1, the trunk rotation test in section 2, and now more precisely in section 3. In the case of this patient, all three sections identified severe restriction.
Section 4: Orthopedic and special testing
I use this time to do diagnostic testing for any painful regions in the body as well as add in additional functional movement testing. Orthopedic testing examples include testing for injuries to the meniscus, labrums, muscle tears, tendon injuries, disc bulges, nerve entrapments, and other musculoskeletal injuries. For this case, we will skip the orthopedic testing and findings that were related to the presenting neck and shoulder pain.
The additional functional testing included a FABER hip test, assessing for the general passive tissue extensibility in the hip joint itself. The goal of this test was to see if any muscle, ligament, or other connective tissue tightness was at play in the loss to hip mobility found in the hip internal rotation testing and Ober’s test. This was found to be positive in the right hip. We also looked at single leg squat and ability to control the knee in a slow descent.
Section 5: Swing analysis
The main goal here from my perspective as a golf rehab and performance specialist to improve the body’s ability to swing proficiently. This means I help create the environment for the golfer to be able to fix swing characteristics without having to compensate elsewhere to do it. This also means that when a swing coach or golf professional instructs you on how to swing or gives you a drill to try, you can effectively, efficiently, and repeatably do the drill without having to make sacrifices at other joints to do it. Here is a video helping to explain the difference…
Here are a few highlights we found on this swing analysis…
1. C posture.
a. This is a set up characteristic noting the positioning of the pelvis and back. Having a C posture is one long curved back. This is the opposite of an S posture where the spinal curves are accentuated and biased towards extension. The C posture puts us in a globally flexed position, taking away range of motion from the hip, pelvis, shoulders, and spinal rotation.
2. Early extension
a. Early extension is the forward movement of the pelvis during the downswing. We would expect the pelvis to stay back while flexion/ extension and rotation occurs. Instead, the pelvis moves forward as the golfer extends.
Putting it all together
We address every finding in the exam, then put it back together as one functional unit. This even includes areas of the foot like supination and pronation, tibial rotation, forearm and wrist mobility, and so on. For the purposes of this article, I will discuss only the major themes in the findings and how they relate.
Multi-segmental rotation:
We first observed this in the section 1 global movement screening. There was a loss of bilateral ability to rotate to the full extent. This can be a motor control or mobility issue. Our golf specific movement screening found this to be true of the thorax (trunk rotation test) and at the pelvis, hips, knees and ankles (lower quarter rotation test). Our joint testing in section 3 identified significant losses in hip mobility, which likely played a big role in our loss of global rotation. Section 3 also found severe loss in thoracic spine rotation, which again would reveal itself in the global rotation movements. The Ober’s test also identified pelvic orientation issues where the golfer was in an anterior tilted position, again limiting the ability for rotation at the hips. We also found an early extension swing characteristic. This is a common issue found in golfers who lack the ability to rotate about the hips and pelvis and instead will extend at these joints to create speed and clear space for the downswing.
So, we know we must address the hips, pelvic orientation and rotation, and thoracic spine rotation especially for mobility. We then need to encourage these regions to start expressing their new range of motion in the actual golf swing. Many times, this requires training to help get sensation and feel back into lateral or side to side hip shifting, strengthening and re-connecting oblique muscles for the purpose of thoracic rotation, and timing and sequencing drills to help get these components moving together appropriately, including the ability to rotate one independent of the other.
In the end, we should see improvements to the TPI tests lower quarter rotation test and trunk rotation test as well as the global movement screen of multi-segmental rotation. We should also notice an improvement in creating separation between rotation components like the thorax and pelvis to make sure we translate these changes to the golf swing (spoiler, we did!). Check out this video showing new ability to create separation in the golf swing.
Shoulder mobility:
Shoulder mobility is important in the golf swing. We especially need front side shoulder internal rotation and back side shoulder external rotation. See why in this video on the mobility requirements for the golf swing.
The upper extremity global movement screen found some limitation here in section 1, while TPI’s assessment found limitations with the shoulder 90/90 test in section 2 with the addition of scapular stability issues. Knowing we needed to take a deeper dive on the shoulder region, section 3 revealed great shoulder internal rotation limitations and missing shoulder external rotation bilaterally. We were able to quantify these mobility issues to help with our re-assessment’s as we began our trial of care.
We also knew that limited shoulder mobility would have effects on our swing, but recent coaching and swing plane cueing from a swing coach prior to the swing video helped clear these swing characteristics for this patient. But, as I mentioned earlier, when we “fix” a swing issue without addressing or assessing the body, we often create compensations in its place. This patient does not have the shoulder mobility to truly achieve an effective and efficient back swing position, so “fixes” to this issue likely resulted in the loss of power, speed, and distance he was needing. The back swing becomes more rigid while his posture becomes more “C” shaped in order to help protract the shoulder blades out and away from the spine, clearing up more space for shoulder range of motion but at the expense of stability and the ability to create speed.
To address the issues identified at the shoulder, we know we need to work on true glenohumeral (shoulder joint) mobility while also improving shoulder complex (including the scapula) stability and motor control. Eventually, we should see improvement (we did!) to the shoulder 90/90 test and the upper extremity shoulder global movement testing which both require mobility and stability at the shoulder. Check out the changes here…
Conclusion
The findings from all 5 sections of the comprehensive exam include much more than what was mentioned here today. Every finding must be addressed individually and with focus, but eventually all the pieces must be put back together again to create real and useful functional change. Phases of care typically follow the scheme of mobility work, transitioning into motor control and stability, then into strength, then power, and last full integration with golf specific drills. Learn more about how we addressed some of these key findings in next week’s article going over treatment plan highlights!
-Dr. Nick DC, TPI, CSCS
If you would like to learn more about your body, pain, and performance, send Dr. Nick an email at contact@integratedrpc.com or call at (585)478-4379, or schedule a FREE discovery visit at Contact.
