Legends Golfer Case Study, Part 1: Comprehensive Exam

This week, let’s discuss a rehab and performance case study with a Vanderbilt Legends golfer. In this case study series, I will show examples of the comprehensive exam first (part 1) while describing the treatment phases and progressions later (part 2). Let’s take a closer look at the exam.

This case was primarily a performance treatment plan, with some focus on recurring pain in the low back and neck. First and foremost, we found pain in the neck and low back that recurred from time to time with cervical rotation and lumbar flexion movements. Sporting history included baseball with lower extremity injuries and no significant upper extremity injuries. The patient was initially referred for treatment regarding rotation to improve his success with golf instruction and performance. It was believed that his thoracic spine restrictions were limiting his improvements and proving adversarial to technique instruction. Now let’s dive into the physical exam.

The physical exam starts with global movement testing. This level of testing essentially calls upon multiple joints to create motion. We can use this level of testing to evaluate how multiple joints work together to create motion and achieve a task. This global movement testing can tell us if there is mobility or stability/ motor control deficit present in the golfer. It doesn’t, however, tell us which one it is or if both are present. It also doesn’t tell us which joint(s) is specifically lacking in either case. What makes this testing so valuable is in telling us we need to take a closer look at the segments involved AND gives us a great pre and posttest to evaluate the success of future integration. More precisely, we are able to take weeks’ worth of joint mobility, strength, stability, and power training/ treatment and see if the individual joint improvements have been integrated into multi-joint global motion. Here are some highlights of what we found from our day 1 global movement testing…

Part 1: Global movement testing (SFMA)

1A) Cervical Rotation

-Cervical rotation proved limited in left rotation compared to right rotation. In the golf swing, we use left cervical rotation when we rotate the body beneath the neck to the right in the backswing (vice versa for lefty golfers). Again, we keep our head and face pointing down in the swing, but when we rotate the thoracic spine and hips below it, we are essentially doing left rotation. If we are limited in this motion, we may be limiting our backswing to keep the head from being pulled along OR we may find swing characteristics that compensate for the missing cervical rotation such as the head moving off the ball or the hips extending and other loss of posture findings as the body tries to re-orient to the ball. Further, the patient had pain while moving into this position. Both of these are important and significant findings for the golf swing.

1B) Multi-Segmental Rotation (MSR)

-We found limitations in MSR in both directions. MSR tests rotation throughout the body, including the ankles, tibias, hips, pelvis, lumbar, and thoracic spine. Here, we had positive findings in both directions, MSR to the right and the left, showing we had either mobility limitations or motor control limitations (or both) in both directions. We are looking for 100 degrees of rotation, about 50 degrees coming from the pelvis and lower extremity and 50 degrees from the trunk. We should expect to see the far side shoulder poke out into view if they are reaching the full required rotation. Here is a video of the before MSR…

Part 2: TPI golf biomechanics testing

Beyond this, we had multiple positive findings in the global movement testing, but we will leave it at these two as the top of the priority list. Next, we do a TPI movement screen. This is similar to the global movement testing, but the movements are much more specific to golf. In fact, they were designed precisely for golf. These tests again will include multiple joints and joint complexes, testing for mobility and stability/ motor control. These tests are from Titleist Performance Institutes (TPI) level one certification. These provide fantastic information about where the golfers body is well equipped or not well equipped to perform a consistent, efficient, and effective golf swing. Let’s look at the highlight from this testing.

2A) Seated Trunk Rotation

This test or screen looks to see if the golfer can reach the minimum of trunk rotation to get into the positions required in the backswing and downswing, without compensations. Now, this is only a screen, and I find this specific test to not be sensitive enough. I have had golfers pass this test that fail more precise and specific thoracic rotation testing. So, I always perform more specific testing that looks at trunk rotation regardless of this test’s findings. That being said, it is still important to have a before and after to re-test later on in treatment.

This patient had failed the trunk rotation test while rotating to the right, but not the left (more precise testing revealed improving left thoracic rotation is still warranted!). If we cannot achieve at least 45 degrees of trunk rotation, then achieving consistent and effective backswing positions without compensation will be impossible. We expect in the screening test here for the sternum to pass the plane of table he is sitting on and rotating towards. Video for this test is often hard to assess, but I will include a brief look at what the test is…

2B) Lower Quarter Rotation Test

This is an essential screen for the golfer. We need to know of the golfer has the hip mobility available, while weight bearing, to get into the backswing and downswing positions without compensation. TPI has found by testing PGA professionals and looking at normative data from the population that we should have access to 60 degrease of rotation in the lower extremity. This means for the downsing and backswing, on both legs, independently. This screen told us that we have severe limitation in both hips for internal rotation. Shown to be true in later testing. It is also hard to see from video the degree of rotation and whether the pelvis crosses the plane of the goniometer, but I will include it regardless to see what the test looks like.

2C) The Lat Test

This test looks at our ability to go overhead without compensation. Again, we are testing multiple areas of the body for mobility and motor control here. Lat length, thoracic spine extension, shoulder mobility, and overall shoulder complex motor control and strength. We found a limitation in both arms with this test. Again, we can’t be sure if this is a thoracic spine mobility issue, shoulder capsule mobility issue, lat length issue, or a motor control issue, but we know to look closer. We would expect the thumbs to reach the wall without bending the elbows or arching the low back. The video is below…

2D) The pelvic rotation test

The last test I will highlight is the pelvic rotation test. Here we are looking for smooth and unlabored rotation of the pelvis without movement from the knees or trunk. This assesses for mobility of the hip and pelvis while also checking for the ability to dissociate the pelvis from the trunk. This dissociation is ESSENTIAL to the golf swing and the kinematic sequence. Here, the patient borderline passed, but we included it on the positive findings to make sure we cleared it up. Check out the videos below on the kinematic sequence and pelvic rotation test.

Part 3: Individual Joint testing

Next, for the third part of the testing, we take a close look at every joint. The previous two sections set us up for a better understanding of what we can expect and what we should definitely take a closer look at, while also establishing great re-test movements to test for integration of our individual joint and strength/ stability improvements into the system. Here are some highlights from the precise joint testing.

3A) Hip Internal rotation

The global movement tests said we had limited multi-segmental rotation. The TPI screen said we had limited lower extremity internal rotation. Now let’s take a close and precise look at the hips. What we found was that we had less than 5 degrees of hip internal rotation on both sides… What we should want is at least 30 degrees of this motion. So, this has jumped to the top of the list as the most important improvement to make to maximally improve the patient’s potential in the golf swing and limit the likelihood of future injury.

3B) Obers test

This test can be used to assess the positioning of the pelvis and the orientation of the femur in the hip socket. The results will tell us how much we need to work on the pelvis to improve sagittal plane issues (we did find some sagittal stability and motor control was needed from the TPI testing with the pelvis rotation, the pelvic tilt test, and the glute with leg extension test). We found positive Ober test findings on both sides, potentially telling us of an anterior orientation of the pelvis that could be improved, especially if we want to improve the hip internal rotation that we found missing above.

3C) lumbar locked test (thoracic rotation)

I mentioned earlier that I find the trunk rotation test can have false negative findings. Instead, I prefer the lumbar locked test to better quantify the amount of thoracic rotation that is present. What we want, again, is at least 45 degrees of thoracic rotation in both directions. Here we find limitation in both sides (not just in right rotation like the trunk rotation found) with rotation numbers coming in at 35 degrees bilaterally. This isn’t terrible but can definitely use some improvement. If you recall, the patient was initially referred due to missing trunk rotation in the backswing from a local swing instructor. This was found to be true, but it seems the real limiter in the backswing was the hips (remember, only 5 degrees of rotation were found in either hip!). So, thoracic rotation is on the list, but the hips and pelvis are the first priority in this case.

Part 4: Special testing

Part 3 included specific testing of nearly every major joint in the body with the highlights of only a few findings listed above. Part 4 will be patient specific. This can include orthopedic testing for patients with pain, special biomechanic testing, or functional and performance testing as needed.

In this case, there was not much needed for special testing. We did lower extremity motor control testing and ankle mobility measurements for dorsiflexion. The motor control testing will be further emphasized later in the treatment plan, and more detailed motor control testing can be done as we get closer to graduating the original treatment plan.

Part 5: Swing analysis

The last thing we will do is look at two videos of your swing. The first video will show face on or lateral movements in the swing and the other will show down the line or sagittal plane movements in the swing. The purpose of these analysis is not to understand better what technical improvements are needed, but how your swing faults are associated with your physical limitations. This helps us to decide which limitations are most impactful to this specific patient’s golf swing, and we also have what will be the most important before and after. For this, I always recommend reaching out and beginning lessons with a golf professional to get technical lessons, especially towards the end of our treatment plan when you most prepared (physically) to make the changes you need. We then look to see these changes present in future swing videos.

Conclusion

So, the general flow of all golf specific day 1 comprehensive exams, is as follows.

1.        SFMA top tier global movement screen

2.        TPI golf specific physical screen

3.        Joint-by-joint mobility and stability testing

4.        Special and orthopedic testing

5.        Golf swing analysis

For different patients, the emphasis on different areas will be apparent. For any golfer with significant acute or chronic pain, there will be significantly more time spent working on orthopedic testing and diagnostic procedures. For pain free patients, more time is spent on the global movement screening and mobility/ motor control. That being said, we will always hit on both the functional components and pain components. Check out the part two article to see examples of how we work through a treatment plan based of a day-one comprehensive exam!

-Dr. Nick DC, MS, 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.

Instagram @Integrated.Rehab.Performance