Nashville Golf and Athletic Club: Case study part 1, the exam

In this article, we’ll explore a case study featuring a local Nashville golfer. We’ll dive into his initial reasons for seeking care, his specific goals, the findings from a comprehensive exam, and will lay out the stages of his treatment plan. Along the way, we’ll highlight examples of the strategies and techniques used to enhance his performance and resolve his concerns. But first, let’s get to know Doug…

Nashville Golf and Athletic Club

Doug is an NGAC member with a passion for golf. His original reason for reaching out was to address mid back stiffness that he could feel restricting his swing, creating tension in his neck and back, and giving him concern about the direction he was headed with his health and mobility. He also noticed some pain in the shoulders while exercising and can have low back discomfort. At 34, Doug wanted to invest in himself for his own health, longevity, and golf performance!

Playing at least once a week in the summer months at NGAC and other clubs in the Nashville area with clients of his, we had to make sure that his body would hold up for years to come.

The comprehensive exam

In our day 1 comprehensive exam, we knew we needed to better understand the extent of Doug’s thoracic spine mobility loss.  He feels his back restricting him in the golf swing, during exercise, and aching while working at the desk. Further, we needed to find the restrictions present in the surrounding joints placing excess stress on the low back and mid back while also identifying areas of weakness, motor control deficiencies, and find provocative movements for his pain and restrictions.

Outlining the comprehensive exam, we have 5 major sections. First, we use Selective Functional Movement Assessment testing to get a better sense of which global movements (involving multiple joints) are restricted and how Doug goes about creating these patterns (motor control). We want to make sure over the course of the treatment plan that these patterns are getting better (improving mobility and motor control integration)

Second, we do a TPI physical exam. This exam is similar to the SFMA, but more specific to golf. This helps tell us where we need to look closer and gives us fantastic data to compare to throughout the treatment plan as we begin to re-integrate our mobility and strength into the golf swing.

Third, we do thorough biomechanics and joint mobility testing, assessing every relevant joint for its passive range of motion capacity. It is important to understand how much movement we can get out of each joint before compensation begins.

Fourth, we do our orthopedic and special testing. When we have pain present, we need to understand better what tissue exactly is involved and to what extent. We also use this section to do special functional testing that is patient specific.

Last, we will do a swing analysis, looking to find swing characteristics that may be associated with the patients’ physical restrictions. We can use this data to help prioritize which physical restrictions are most important.

Part 1: SFMA

With Doug, the most important findings from the SFMA top tier exam was a cervical rotation restriction to the right, Multi-segmental rotation limitation to both sides, and a multi-segmental flexion restriction. Let’s look a bit closer at the cervical rotation restriction and multi-segmental rotation restriction…

Cervical rotation is exceptionally important for the golf swing. Though we keep our head and eyes down on the ball through the backswing and downswing, our trunk is rotating below us. This means we are essentially creating full left and right cervical rotation regardless. If we can’t rotate the head fully, then we will either limit our trunk (shoulder) turn since it will start dragging our head OR we WILL drag our head and lose posture.

Multi-segmental rotation is testing our motor control, stability, and mobility in rotation over multiple joints. The foot all the way up to the thoracic spine and every joint in between is used to create 100 degrees of rotation. If we can’t get the far side shoulder to poke out while doing this test, we know we haven’t reached 100 degrees of rotation and need to look closer at these joints to see where the mobility or stability/ motor control is limited. Further, we need to retest this movement throughout the treatment plan to make sure we are integrating our mobility and strength improvement s back into global and weight bearing motor patterns.

Part 2: TPI Physical Screen

This part of the exam focuses on golf specific motor control and mobility. Doug’s positive findings were numerous, but a few big ones included the lat test, the pelvic rotation test, and the lower quarter rotation test. The lower quarter rotation test is a significant test, but difficult to see well on video. We will exam the components of that test during our biomechanics exam… Let’s take a closer look here at the lat test and the pelvic rotation test.

The lat test shows us not only the mobility at the shoulder joint but also assess the stability and strength at the entire shoulder complex. Further, we challenge this overhead position while maintaining the low back and mid back firmly against the wall. This means we must have access to posterior tilt at the pelvis and thoracic spine extension. The constraints of this test limit the golfer from compensating at the shoulder or the low/ mid back. In this way, we assess the ability for compensation free shoulder flexion.

In Doug’s case, we had major asymmetry in the ability to raise the arm overhead. The fact that this was unilateral (one sided) indicates this restriction was less likely due to thoracic spine or pelvis mobility or stability issues and more likely a true glenohumeral restriction. To improve on this, we know we need to look closer at the shoulder joint, scapular stability, and muscle tightness around the shoulder.

The pelvic rotation test helps us identify the restrictions in hip, pelvis, or low back while also identifying the patients motor control over these segments. The rotation of pelvis without movement (stability) at the trunk is vital for creating the correct sequencing in the downswing, creating lag, and improving efficiency and power in the swing! Doug showed some issues getting smooth rotation from side to side. Instead, there was a high motor drive to make this particular motion happen and with limited overall motion.

Part 3: Biomechanics and joint mobility

In this part of the exam, we look at the passive range of motion at the spine, hip, shoulder, knee, ankle, and ribcage in all three planes of motion. In Doug’s case, the most significant findings included hip internal rotation and thoracic spine rotation.

This test here is the “lumbar locked test”. This test assesses the golfer’s ability to actively rotate through the mid back while limiting compensation that can come from the low back. This gives us a great true assessment of the thoracic spine, an immensely important region for the golf swing.

In Doug’s case, he was severely restricted in his ability to turn through this part of his spine. In this case, he was correct about his mid back being a limiting component to his swing. What we want normally is 45 degrees or more of thoracic spine rotation in both directions. Here, we had about 25 degrees of rotation measured bilaterally. This motion would have impact not only on this test, but also our multi-segmental rotation test and other mid back extension tests like the lat test.

When we start struggling to move well in this part of the spine, we will be quick to see compensations that try and pick up the slack. This includes increased rotation in the lumbar spine (low back), increased magnitude of rotation and abduction/ adduction (side-to-side) movement at the shoulders, or increased magnitude of forces and rotation at the hips and knee joints. These physical compensations can increase our risk of injuries (see the Tiger woods 5-part series in the blog archive!) and create swing compensations that affect our performance.

As I just mentioned, missing thoracic spine rotation can have a big impact on the joints around it, forcing other areas to pick up the slack and potentially cause injury. The hips were one region where this can happen. Unfortunately, in Doug’s case, he also had big restrictions in hip internal rotation mobility. We found this in the Multi-segmental rotation test (not specific for the hips), the TPI lower quarter rotation test (assessing ankles, knee, and hip/ pelvis), and now confirmed hip rotation restriction specifically. Further, TPIs lower quarter rotation test indicated hip internal rotation was limited on both sides. We see this on the backswing for the backside hip and on the downswing for the front side hip.

Doug was showing passive access to 12 degrees of right hip internal rotation and 10 degrees on the left hip. What we would want is 30 degrees of access on both sides.

Now, with both significant thoracic spine and hip rotation restrictions, we have high potential for low back injury in the future as a place for major compensation trying to pick up the slack for the joint above and below it. We also show major performance limiters as combined access to rotation is missing.

Part 4: Orthopedic and special testing

For this NGAC golfer, we did not have significant pain or injury to work on. Therefore, we did not have much in terms of orthopedic testing to be done. However, we did have some special testing relevant to his case. The TPI exam showed an excessive use of the hamstrings in a glute bridge test, meaning Doug was using the hamstrings to create hip extension over his glutes. With some work to be done on the pelvic tilt and pelvic rotation test as well, more testing around glute activation was warranted. For this, we did a prone hip extension test to take a closer look at his ability to control the pelvis and hips with the glutes.

This test conformed an over-activation of the hamstrings, and low back to create extension with minimal glute.

Part 5: Swing analysis

During Doug’s swing analysis, we saw a few swing characteristics that corelated well with his physical screen. First, his set up position showed a C-posture. That’s that rounding through the mid back of the entire spine as he sets up to the ball.

Further, we saw that Doug has a little over-the-top swing characteristic. Missing the ability to separate the trunk from the pelvis, shoulder mobility issues, and rotation restrictions can all effect and instigate this over-the-top characteristic.

Comprehensive exam key points

From the highlights I mentioned here, our exam had many significant findings. Overall, we established the number one issue to address was global rotation. We found severe restriction in the thoracic spine and both hips. Golf being a violent sport demanding explosive rotation, we need to improve this for performance, pain and discomfort, and longevity. Both of these regions are placing extra stress onto each other as well as the region between them, the low back.

 To avoid major problems in the future, we needed to dial in the passive range of motion, active strength, and motor control to these regions. That being said, we must also integrate the use of the hips and thoracic spine back into the golf swing. We can’t expect golfers to integrate new movement patterns into their swing without showing them how!

Conclusion

Doug is an avid golfer who successfully negotiates the challenges of NGAC every week. He has experience tearing up other local courses, including shooting a 76 at Troubadour this year. That being said, he feels his mid back stiffness becoming a problem that is limiting his full potential. He also wants to be able to exercise and play with his kids pain free for years to come. Day 1 comprehensive testing has shown we do have extensive thoracic spine restrictions along with hip and pelvis mobility/ motor control deficiencies. Further, we can work on improving shoulder overhead and external rotation range of motion to further address the compensations occurring throughout his body in the swing.

To do this, we committed to a 12 session, 1-on-1 treatment plan. These sessions include hands on work, chiropractic technique, and corrective/ performance exercise and drills. Check out part two to dive in more on the treatment plan designed specifically for Doug!

-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.

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P.S. if you have mobility deficits, joint restrictions, pain, or injury that is limiting or holding you back in golf and fitness, consider how regional interdependence is at play and impacting your ability to recover, create swing faults, and lead to continued pain and injury.