Dr. D. Ryan York, PT, DPT, CGS Doctorate in Physical Therapy Certified Golf Performance Specialist, GOLO Golf University
Dr. Chad Edwards, PT, DPT, CGFI Doctorate in Physical Therapy Certified Golf Fitness Instructor, Titleist Performance Institute
© 2014 by Age Defying Golf, Boise, ID. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of Age Defying Golf.
Table of Contents for Foundation
Introduction and Purpose
Chapter 1. Osteoarthritis and Golf
Chapter 3. Back Rx for Low Back Pain
Chapter 4. Neck and Upper Back Rx
Chapter 5. Shoulder Rx
Chapter 6. Wrist and Hand Rx
Chapter 7. Balance Rx
It is recommended that you consult your physician before starting an exercise program. This book offers information in regards to fitness, exercise, physical therapy, sports medicine, and golf training. The information in this book is not medical advice and is not meant to diagnose or treat specific injuries or disease.
2 Chapter 1. Introduction and Purpose
Welcome to the Guide to Pain-Free Golf. This book is generally intended and written for golfers over 50 years old that are beginning to experience pain in their golf game that is limiting their ability to play and enjoy golf. As you probably know, golfers
(and people in general) over the age of 50 begin to feel the effects of “age” in their daily function. Back pain when lifting a box, shoulder pain when reaching up into a cupboard, that jolt of neck pain when checking your blind spot while driving, etc. All of these issues can break down and spoil a wonderful round of golf. A successful golf swing is largely dependent on rhythm. If you have ever played a round of golf with pain, you likely have noticed this disruption of a smooth rhythm due to sharp pain at the top of your backswing, impact position, or follow through that limits your swing. It’s not much fun and, at worst, causes many golfers to give up golf, and at best, causes golfers to limit their swing to avoid the pain which can dramatically reduce power. This Guide is intended to address the most common injuries and/or pain we see from golfers in our clinic. However, since we are not able to personally examine each golfer who reads this book, we STRONGLY recommended that you consult your physician before starting any rehabilitation procedure in this book. This book offers information in regards to fitness, exercise, physical therapy, sports medicine, and golf training. The information in this book is not medical advice and is not meant to diagnose or treat specific injuries or disease.
Chapter 1. Osteoarthritis and Golf
3 Osteoarthritis is the irritation of joints due to the breakdown of cartilage that covers the bones that make up those joints. Osteoarthritis is one of the most common diseases in the United States, and is especially prevalent in people over 50 years old. The most troublesome joints that most commonly cause pain in golfers are the knees, hips, lower back, and wrist/hands. Typically, symptoms are aggravated by too much activity, too little activity, and/or cold. If not addressed, we find that most people respond to this pain by resting or staying off their feet. However, this option results in weak muscles and decreased stability in the joint. Decreased stability means more pain and increased joint damage, not to mention decreased coordination, flexibility, and poor posture. So the obvious advice is too stay active but don’t push it.
Only your doctor can diagnose you with osteoarthritis. A diagnosis occurs after taking a medical history, ruling out traumatic causes, and usually and X-ray.
Before we discuss conservative measures that we use in physical therapy to treat osteoarthritis, you should also be aware of several issues to discuss with your physician.
If you have been diagnosed with osteoarthritis, the primary goal of treatment is reduce pain and preserve function. Having a knee replacement is a good option, but it should be considered the last option. Rehabilitation from a knee replacement surgery is difficult and lasts between 3 months on average. In addition, having an artificial knee usually means the end of impact related sports such as running, basketball, volleyball, and sometimes snow skiing.
4 First, your physician and pharmacist can discuss the risks and benefits of prescribed medications. The primary role of medication treatment is control pain, which will allow you to maintain your level of activity and exercise to keep muscles strong and joints stabile. However, no drugs as of yet have been proven to re-grow or heal damaged cartilage. The most commonly prescribed or recommended drug for treating osteoarthritis are non-steroidal anti-inflammatory drugs, also known as NSAIDs. These drugs do have side effects, so it is very important to discuss use and dosage with your physician.
Second, corticosteroid injections are commonly used by physicians to reduce pain and inflammation. Many patients lament that corticosteroid injections just make it feel better but after the injection wears off they will be right back where they started….so what is the point? This is only partially true because one of the primary damaging effects of arthritis is inflammation. Prolonged inflammation can definitely exacerbate arthritis and cause more damage, so it sometimes is valuable to have a corticosteroid injection to reduce inflammation and, thus, reduce damage to the joint. However, like most medications, corticosteroids have sideffects if given in too high a dose or with prolonged use, so it is important to understand the risks and communicate with your doctor if you incur any physical or mental abnormalities.
Next, a fairly new and effective treatment in the battle against osteoarthritis of the
KNEE is called Synvisc. Synvisc is a viscosupplement that is administered by a physician as a series of 3 shots given over 3 weeks. It is purported to cushion and lubricate your
5 knee joint to relieve friction and provide increased motion and decreased pain for 6 months. In my experience as a physical therapist, patients who have received Synvisc injections from their physician have faired very well and have been able to return to their previous level of activities with minimal to no discomfort. Side effects are reported to be mild and rare. If other efforts have failed to bring you relief, and you are considering a knee replacement, I encourage you to talk to your doctor about Synvisc.
Finally, the last resort is a complete knee replacement (TKA). If you are a VERY active person, it may we worth your while to talk to your surgeon about the possibility of having a high tibial osteotomy or a distal femoral osteotomy. Other contraindications, or reasons not to have a knee replacement include: active knee infection, if your knees are naturally hyper-extended (bent backwards), severe obesity, if you are planning to return to high impact sports, and/or arterial insufficiency (blood supply problems to the legs) which can be caused by severe diabetes, etc.
After you have decided that a total knee replacement may be right for you, it is wise to consult with several surgeons as well as ask for referrals from your physician. Physical therapist can also help advise you on which surgeons have the best reputation and results.
Choosing the right surgeon can improve your outcome dramatically.
Countless studies have proven the effectiveness and importance of seeing a physical therapist BEFORE you have your surgery. Your physical therapist can prescribe an exercise program to help stabilize and strengthen around your joints that will decrease the
6 time needed for post-surgical rehabilitation. I have found that the patients that participated in a pre-surgery exercise program faired much better by far, than those who did not participate.
After you have the surgery, little explanation is necessary here because all the guidance and care you need, will be given to you by your physician and physical therapist.
Like I mentioned earlier, rehabilitation can take up to 3-6 months depending on your current level of health, fitness, your age, and your ability to exercise independently. If possible, schedule your surgery sometime between the end of September and the beginning of November so that you will be ready to tee it up again when the golf season begins.
If you and your physician have decided that other, more conservative measures would be better, physical therapy can play a large role in the treatment and management of osteoarthritis. Conservative treatment is focused on managing the disease and preserving or increasing function.
Conservative Measures to Treat/Manage Osteoarthritis
I. Weight Management II. Heat vs. Cold Treatment III. Exercise IV. Transcutaneous Electrical Nerve Stimulation (TENS) V. The Joint Friendly Golf Swing
I. WEIGHT MANAGEMENT
7 Weight management is one of the easiest answers to controlling arthritis, but may be the most difficult to carry out. As mentioned earlier, osteoarthritis occurs when the protective cartilage covering the ends of bone is worn away. So when two bones interact together in a joint, say your knee joint, the bones grind against one another instead of gliding smoothly. As a result, the heavier you are, the more pressure you will place on the weight bearing joints of the body, such as the hips, knees and ankles. You are pressing the irritated bones closer together which makes it even more difficult for them to move, creates more grinding, more inflammation, more damage, and more pain. The great thing about losing weight to decrease your joint pain is that any amount of weight that you are able to lose helps. You don’t have to lose 100 pounds before you get any relief, if you lose
5 lbs it will make a difference!
Age Defying Golf Rx is not a weight loss program per se, but many people who do the program as it is intended, do lose weight. If you believe that you need help to lose weight, I strongly recommend that you seek out a personal trainer. 90% or more of people who need to lose weight fail, so do not feel bad if you have tried before. I personally believe the key to success is seeking out help. Find a personal trainer, dietician, workout partner….whatever it takes. Don’t set yourself up for failure by having too high of expectations. Weight loss and being healthy is a complete lifestyle change, so be patient.
Having a background in personal training and physical therapy, I feel that the number one reason that people fail to stick to a lifestyle change is that they try to do it on their own.
8 Being healthy and exercising on your own only works if you have already created a habit of being healthy and exercising. DON’T GO IT ALONE, seek out help and find a partner as dedicated as you are!
II. HEAT VS COLD TREATMENT
I am always surprised at the confusion of when to use cold treatments versus hot treatments for pain and injury. Here is your basic advice (there are a few exceptions): Use a cold pack or ice if you have a recent injury, inflammation, and/or redness and swelling.
Use heat for tight or sore muscles, after the initial phase of the injury has passed (14 to 21 days past injury depending on severity), and for arthritic joints most of the time. I say
‘most of the time’ because whether to use heat or cold on arthritic joints depends on the current state of the joint. If your joint is in an irritated state, such as occurs after exercise, after a round of golf, if you “tweak” the joint, etc., this is the time to use ice. All other times use heat! Heat increases blood flow to the joint and reduces stiffness.
Application Instructions
Cold Pack. You can purchase an ice or cold pack at most drug stores and sporting goods stores. In our clinic, we use gel cold packs that you can tightly wrap around joints and secure with a Velcro wrap that is attached to the cold pack. These packs can be pricey, so if you want a low cost option, nothing beats a frozen bag of vegetables, particularly frozen peas. These surround and mold to the shape of your joint and work great. For use, place a cloth or paper towel between your skin and the cold pack to prevent
9 burning your skin. Elevate your leg on a footrest or the arm of your couch and apply the ice for 10-20 minutes. If you would like to ice your joint again, make sure to wait at least
2 hours first. Applying ice for too long or applying it too frequently can sometimes cause tissue injury.
Heat. Heat can be administered in a number of ways. If you have OA, you are probably the stiffest and in the most discomfort first thing in the morning. You have spent the last 6-8 hours in relatively the same position and your joints have stiffened up. Your first line of defense is an electric blanket or a heating pad in your bed. Turn it on before getting out of bed to heat up the joint. You can start moving the joint through its range of motion as it warms up. Next, hop in a warm shower or bath. If you have OA, you may have already figured out how helpful and pain relieving warm water can be. To finish of your morning ritual, place your clothes in the dryer for a few minutes before you put them on. Now you are ready to face the day, or the 1st tee.
Heat is also an excellent choice before you exercise or partake in any physical activity. Use it directly on the joint or on sore muscles. Finally, use a heat pack or heating pad when you get into bed before you go to sleep. This will help calm achy joints or muscles so you can rest. Make sure to turn off the heat before you go to sleep or you might end up with a nasty little burn.
Other instructions for heat application include: use a towel between your skin and the source of heat, never use a heating pad for longer than 25 minutes, if the heating pad
10 feels too hot it probably is and you are at risk for a burn, and if you have compromised sensations (such as with diabetes) check your skin every 5 minutes for excessive redness.
You need to be aware that it is very easy to burn your skin with a hot pack. Since the pack heats up gradually, you will not feel the pain from a burn until the next day, so always be cautious.
III. EXERCISE
If you want to avoid a total joint replacement, exercising in some form daily is a requirement. Exercise will help you maintain your flexibility, stabilize and further protect your joints, maintain an active lifestyle, and keep your body strong.
An exercise program designed for a person with OA can be very different than your standard exercise program. It should be a well-balanced exercise program with a variety of exercises focused on range of motion 1st, endurance 2nd, and strengthening 3rd. It is important to note that if your arthritis is flared up (joint is warm and swollen), you should only perform gentle range of motion exercises until the joint calms down. In this situation, strengthening will only increase inflammation and could further damage your joints.
1. Range of Motion – Range of motion is the normal range that you can move your bones about a joint. For example, your knee should be able to bend approximately
1350 and should fully straighten to 00. Thus the normal range of motion for the knee joint is 00 – 1350. You should move all of your joints through their full, available range of motion daily. This will help you maintain your flexibility and movement, which is very
11 important for golf and maintaining your current lifestyle and independence. It will also increase the natural fluid in the joints that helps the bones glide more fluidly across each others surfaces. Remember, “motion is lotion” for your joints, so keep them moving…every day and even if it is somewhat painful. (Daily activities such as house or yard work DO NOT move your joints through their FULL range of motion).
2. Endurance – or conditioning is also very important for maintaining the condition of your muscles and increasing the blood flow and warmth to your joints. This can be difficult because weight-bearing exercises (such as hiking, jogging and sometimes walking) can be painful and damaging to your joints. Instead, ride a bicycle or do exercises in the pool to reduce the compression and grinding of the joint. Walking is an excellent exercise if it does not bother your joints too much. Generally speaking, you should participate in some form of endurance exercises 3-5 times per week and work up to
20-30 minutes per session. Also, the first month of performing endurance exercises can difficult because your body is not used to them. However, after the first month or two, you will begin to enjoy more energy and good feelings following your workouts. You are going to feel better and enjoy golf much more.
3. Strengthening – Strengthening is important to stabilize and reduce the stress on arthritic joints. The intensity of exercise that is best for you is dependent on the level of pain and damage to your joint, your tolerance for weight bearing, and whether or not your arthritis is in a state of exacerbation (flared up). I strongly encourage you to consult your
12 physical therapist to develop a plan that will provide you with the most benefit without increasing joint damage. Without evaluating you myself, the best recommendation that I can give you is: 1) try to perform exercises that cause minimal to no pain, 2) do not exercise if your joints are warm and swollen 3) the best exercises for arthritis of the hips, knees, and ankles are performed in the pool.
IV. TENS (transcutaneous electrical nerve stimulation)
TENS is an effective treatment for osteoarthritis that is safe, noninvasive, and drug- free. I encountered more and more patients in my clinic that do not want to, or want to limit their medication use. A TENS unit is an excellent option.
A TENS unit delivers a comfortable electrical stimulation to skin and muscles around a painful area. Patients describe the feeling as a “buzzing” or “pulsing” sensation.
TENS works in two main ways to limit or eliminate pain. The first pain relieving mechanism uses the principals of the gate theory of pain. This simple to understand theory basically states that the brain can interpret only one sensation from a certain area of the body at a time. For instance, if a bee stings you, your first instinct is to scratch the area.
The scratching of the painful area overcomes or interferes with the pain message and less pain is felt. The sensation of the TENS unit is specifically tuned to completely take over the sensation of whatever area it is applied to. Second, the TENS unit stimulates the release of enkaphalin from the central nervous system and endorphins from the pituitary gland, both of which provide pain relief that can last for several hours.
13 Typically, a TENS unit is a small electrical unit about the size of a walkman radio
(if you can still remember what a walkman radio is) that can be clipped on your belt and even put in your pants pocket. Two to four wires extend from the TENS device to sticky electrode pads that you stick to your skin around the painful area to be treated. You can use it anytime, even on the golf course so you can play a pain-free round. Generally, a 20- minute treatment will reduce or eliminate pain for up to 4 hours at a time. Approximately
95% of the patients that I treat with TENS love it.
If you have osteoarthritis, almost all insurance companies will buy you a TENS unit as long as you obtain a prescription from your doctor. They would much rather pay the small price for this unit ($100-$900) than pay for years of medications or a joint replacement surgery that costs tens of thousands of dollars.
V. The Joint Friendly Golf Swing
There are several adjustments that you can make to your golf swing and golf game that can reduce the stress and strain on your back and joints.
Setup. In your golf setup, make sure that you stand tall with your back flat. Try not to hunch or bend over too much. To help with this you can try longer golf clubs and you should absolutely look into long putter. You should already have your left foot toed out about 20-300 at address, but you can reduce the strain on your right hip and back by turning your right foot outward as well. This position may make it more difficult to be still, so
14 make sure that your right knee does not straighten or slide as you take your backswing.
You might also want to try a more closed or open stance at address. Generally, a closed stance will help reduce strain during your backswing and an open stance my reduce strain through impact and to follow through.
Golf Swing Adjustments. Go ahead and allow your left heel to come off of the ground during your backswing. It is not as important as many people think to keep your left heel down. You will see lots of senior professionals on the PGA lift the left heel. It is much more important that your right knee is stable during your backswing. You may also need to shorten your backswing and follow through swing. As golfers get older with more joint pain, it becomes more important to concentrate on the width of your swing than the length of your swing. So shorten up your swing and focus on width for power. Finally, as you follow through to the finish of your swing, allow the right foot to be dragged forward instead of being planted. This will reduce the strain on your left hip. In severe cases of left hip osteoarthritis, we have successfully taught players to walk towards their target a few steps after they hit the ball. Try the “walkthrough drill” in the ADG Drill Book.
Around the green. As mentioned earlier, you should definitely try a long putter to reduce stress on your back. Also, make a conscious effort to lean on your putter when reading putts or retrieving your ball out of the cup. There are rubber ball retrievers that you can stick on the end of your putter so that you do not have to bend over to pick up your ball.
15 Additional Tips. A lot of older golfers are switching to larger grips to reduce pain with arthritic hands and fingers. However, remember that the bigger your grips are, the greater your tendency to block the ball to the right because it is more difficult to rotate the club face to square at the impact position. If you have a lot of pain in your wrists, hands, or fingers you should also consider hitting the ball off of a tee with all shots. Light graphite shafts can also help. And remember; never, ever carry your golf bag on your shoulder or back!!! Even pull carts can be painful to your shoulder. I suggest using a pushcart, a powered push/pull cart, or living the good life and riding in a golf cart.
In addition, it is important to seek out a good physical therapist that is a good golfer or, even better, is a trained golf teacher. These professionals can give you strategies that are more specific to your exact diagnosis and pain.
Chapter 2. Back Rx
Introduction
If you are an avid golfer over 50, 90% of you have experienced back pain that affects your golf game. Back pain can result in a compensated movement pattern that can lead to acute and chronic conditions that not only affect your golf performance but lead to an early golf retirement. Back pain is the number one injury leading to missed golf rounds, a terrible way to live!
Differential Diagnoses and Non-Orthopedic Causes of Back Pain
16 Any discussion of low back pain must begin with the knowledge that not all causes of low back pain come from the low back. In addition, some of the causes of low back pain are not the result of bone, muscle, or nerve dysfunctions and, therefore, will not be affected with physical therapy interventions. It is not the intention of this book to diagnose or treat serious pathology, but to provide general information and safe corrective exercises that will reduce and prevent most causes of low back pain. If you experience any of the following “red flag” symptoms, I strongly advise you to consult your physician immediately.
Red Flags
1. Sudden and unexplained or unexpected weight loss.
2. Night pain that is not relieved by getting out of bed and walking around.
3. Constant, unvarying pain that persists beyond 3 weeks.
4. Any changes in bowel or bladder function.
5. Numbness or tingling in the “saddle” area.
6. Changes in leg strength of both legs at the same time.
In addition, we often find that the cause of low back pain is not the low back. It is beyond the scope of this program to treat “other” causes of low back pain. As a result, if the exercises in this book do not eliminate your low back pain, I advise you to be evaluated by your physician AND your physical therapist to determine the best course of action.
“Other” treatable causes of low back pain include the following: Leg length difference,
17 pelvic rotations, poor leg mechanics and/or limping, flat feet, feet with high arches, hip weakness, lack of flexibility of the leg muscles, pelvis dysfunction, hip dysfunction, etc.
Finally, I recommend that you see your physical therapist or chiropractor to determine if your back is out of alignment. Being “out of alignment” can mean that one of your vertebrae (bone in your spine) is stuck in a rotated, flexed, side bent, or extended position. It can also mean that as you bend forward or backwards, the vertebra does not move correctly or gets stuck. This can easily be corrected with a few sessions by a skilled physical therapist or chiropractor. However, the difficult part is retraining the muscles to maintain the correct spinal alignment. As a result, any alignment correction should be accompanied with a spinal neuro re-education protocol. If you find that you are continually needing to be “adjusted,” find a different practitioner. Permanent correction of a spinal alignment problem should take no more than a couple months. Being a physical therapist, I am of course biased towards my own profession. However, the bottom line is that you get better and stay better. Whether physical therapy or chiropractic care gets you there is of little consequence.
TYPICAL CAUSES OF LOW BACK PAIN
I. Posture II. Poor stabilization III. Weak Core IV. The Disc V. Sciatica
I. Posture
18 What is posture? Posture is the relational position of the joints in your body. It is easily defined. What has been proven to be much more difficult to define is what is
“good” posture. For the purposes of our discussion, we will define good posture as the position of your joints in relation to each other that causes the least amount of stress to joints. Factors that affect your posture include such things as heredity, your environment, disease (ei. Scoliosis), and/or habit. The two factors that are the easiest to correct are your environment and habit.
A. Your Environment.
“Your environment” includes such things as the chair you sit in, the height of your computer at work or home, the physical requirements of your profession, the mechanics of your golf swing, etc. In my practice, I often find that simple repetitive movements performed day after day can eventually result in major back pain. For instance, a professional that has his/her computer set up to their left on their desk, instead of directly in front of them, will spend their day rotating their back to the left to face the computer.
After spending enough time rotating to the left, the muscles on the left will get short and tight and the muscles on the right side of the spine will get weak and long. You can see that tight muscles on the left of the spine would restrict a right handed golfer from taking a full back swing and would likely cause a lot of back pain after a round of golf. Other common examples of an environment that can lead to back pain include: gardening, sitting
19 in a chair that is too high or too low, counter spaces that are too low, any repetitive rotational movements, etc. There are many sources on the Internet that give recommendations on proper workspace set up.
Of course, in an ideal world we could properly adjust all situations and activities so that they would be “back friendly.” However, since we live in the real world we must come up with strategies to protect our back when our job or situation requires us to perform difficult movements. In this next session we will discuss techniques you can use to find “good posture,” and techniques to help you stabilize and protect your spine.
-The Pelvic Tilt-
The best position for your spine is what we call “spinal neutral.” This is the theoretical position in which there is the least amount of stress placed upon all of the joints in your spine. To find spinal neutral in a standing position, first place your hands on your hips. From this position, roll your hips as far forward as you can (stick your butt and stomach out at the same time). Next, roll your hips backward as far as you can (tuck in your tailbone). From this position, roll your hips forward 10% and you have found spinal
20 neutral, your “correct” posture. Whenever you are performing any strenuous activity, you should find this position and maintain throughout the activity.
To find spinal neutral in sitting, begin by slumping forward with poor posture.
From this posture move in the opposite direction, raise up your chest and sit super tall in an exaggerated upright posture. From this position, back off 10% and you have found spinal neutral in a sitting position. The best way that my patients have found to learn this posture is to set a timer to go off every 10 minutes while you are sitting to remind you to find your spinal neutral position. Why, you may ask, is it so difficult to hold this position?
The answer is that your body will relax according to the path of least resistance. Over the years of sitting and standing with poor posture, the length of your muscles has changed to so that your body “thinks” that the poor posture is your normal posture. As a result, whenever you sit with good posture, you are essentially resisting the pull of your muscles and as soon as you think about something else, your body will relax in the position of least resistance. In order to correct this imbalance, you need to change the length of your muscles. Stretching your tight muscles and strengthening your loose muscles in the correct positions can accomplish this. First we must find the correct muscles to influence, and luckily, most of us have problems with the same muscles and we end up in a posture that is defined by “Lower Crossed Syndrome.”
- Lower Crossed Syndrome -
21 If you are slightly to very overweight, you are at a higher risk of developing this syndrome. If you are a woman and were high heels regularly, you also are at risk for developing this syndrome.
Lower Crossed Syndrome is the combination of weak and overstretched abdominal muscles (stomach), strong and tight low back muscles, weak gluteal (butt) muscles, and strong and short hip flexor muscles (front of hip). This combination usually leads to the feeling of a “tight,” sore, and achy low back. If you have a belly that sticks out and your low back muscles are stiff and firm to the touch, you may have a Lower Crossed
Syndrome.
“Syndrome” is a somewhat ominous term for describing an acquired poor posture.
It can be easily corrected with the exercises in this program performed 2x’s per week.
However, it is a slow process and can take several months to correct. If not corrected, you run the serious risk of developing major back injuries, surgeries, and an early retirement from golf.
**An important fact to know is that the posture described above can sometimes be caused by more serious and urgent alignment issues such as a condition called spondylolisthesis, which is when one vertebra has “slipped” forward out of alignment. If you experience intense radiating symptoms, bowel or bladder change, or a pinpoint sharp pain, you should make an appointment with your physician immediately. Exercises: To counter Lower Crossed Syndrome, perform the following exercises
2-3 times per week: Exercise: 1, 3, 5, 6, 7, 10 found at the end of the Back Rx chapter.
22 II. Poor Stability (HYPER-mobility) versus Stiffness (HYPO-mobility)
When a spinal joint moves too much it can be defined as a HYPER-mobility. If a joint is stiff and does not move very well we can define it as a HYPO-mobility. A back fusion surgery results in a very HYPO-mobile joint, it no longer moves, it is fused.
Generally, when a person has an overall stiff back, they will have HYPO-mobile back. Of course, back stiffness can limit a golf swing and result in the loss of power.
However, our concern in this section is HYPER-mobile joints because HYPER-mobility often results in back pain. Here is what you must know; nearly all stiff and HYPO-mobile backs will have a HYPER-mobile joint. This joint may or may not be painful.
Here is one method you can use to assess yourself to determine if this applies to you. It is not a perfect test, so you may have a HYPER-mobile joint even if you do not find anything on this test. However, if you do find something, you may almost certainly have a situation in need of treatment. You will need a partner and a black marker.
Begin in standing with your shirt off and have your partner stand behind you with the black marker in hand. Have your partner mark a straight line down the middle of your lower back along the spinal bones. Next, tilt your back to the left making sure that you tilt without bending forward or backward or rotating. The black line should make an even curve towards the left. If the black line is not an even curve (ei. straight line or line with straight spots and curved spots) you may have a HYPO-mobile back with 1 or 2 HYPER- mobile segments. Next, test yourself tilting your back to the right.
23 Finally, test yourself bending backwards. If there is an obvious “kink” in the bend of the spine or a specific area where all the motions takes place (instead of bending the whole spine) this can also be an indication of hypo-mobility combined with hyper- mobility.
If you find that your spine does not move normally, perform the following exercises
2x’s per week: 3, 4, 7, 8. Perform exercise 9, EVERY DAY found at the end of the back
Rx chapter.
**This condition can be difficult to correct. If you do not see results in the first 4-6 weeks, consult with your physical therapist for further treatment. As an additional note, painful hyper-mobility in the back can also be caused or made worse by tightness in the hips. If the hips don’t move well, you may be gaining the extra motion you need from your back. As a result, stretching out your hips and legs may ease the stress on your low back.
III. Developing the Core
Many times back pain is the result of overall weakness in the core, or spinal stabilizing muscles. The best stabilizing muscles referred to as the “core” include the transversus abdominus, internal oblique, lumbar multifidus, and the quadratus lumborum.
These muscles are addressed throughout the Age Defying Golf Rx system. If you feel or have be told that you need to work on core strength, add the following exercises to your program: Exercise 3, 4, 5, 6, 7 found at the end of the back Rx chapter.
24
IV. The Disc – Too Often Blamed
There have been recent studies that have shown that most adults without back pain have disc protrusions, or disc bulges, as shown by MRI testing. In my practice, I often see patients with back pain who are referred to me for treatment with the diagnosis of a disc bulge. However, I rarely find that the patient’s disc bulge is actually the cause of the patient’s low back pain! Even worse, I see too many patients referred to me for treatment after a back surgery for a disc bulge has not resolved the patient’s pain. As a result, the patient continues to have his original symptoms, but now has to deal with a difficult and painful rehabilitation from surgery. If you have been diagnosed with a disc bulge, please get a 2nd and even a 3rd opinion. Try conservative measures such as physical therapy before you agree to surgery. World renowned physical therapist and researcher Robin
McKenzie has developed a successful self-test and self-treatment for people who have a disc protrusion. Here is a brief introduction his treatment method.
**For further information on the McKenzie method, I recommend his book, Treat Your Own Back, by
Robin A. McKenzie.
A. The flexion-extension test
From a standing position, bend forward reaching forward to your toes. Do not hold this position, but repeat it 12 times. If this position causes pain but does not get worse with each repetition, a disc bulge is unlikely. However, if symptoms get worse with each
25 repetition, and especially if you experience radiating symptoms into your buttocks or down your leg, you may likely have a symptomatic disc bulge.
Next, bend backwards from a standing position. Again, do not hold this position, but repeat it 12 times. If you have a symptomatic disc bulge, this motion should reduce your symptoms and reduce any radiating symptoms.
If these tests indicate that you may have a disc bulge, see your physician. You can also try McKenzie’s treatment, Exercise 2, found at the end of the Back Rx section.
Perform multiple times during the day and whenever your back hurts. Stop immediately if symptoms worsen.
**A condition called a disc herniation may be present if you experience radiating symptoms below your knee. If this occurs, see your physician for an evaluation.
V. Sciatica
Sciatica is defined as pain along the course of the sciatic nerve. Typically, patients will report a radiating pain from the buttocks down that back of the leg, calf, and under the foot. Sciatica can be caused by a disc herniation, spinal stenosis, and what I find most commonly, tightness and spasm of muscles that pinch down on the nerve. The most common culprit is the piriformis muscle located underneath the gluteus maximus (butt muscle). If you are diagnosed with “Sciatica” you should ask where and what is impinging on the sciatic nerve.
26 If you find that tight gluteal muscles or the piriformis muscle is at fault, you may be diagnosed with Piriformis Syndrome. The classic signs of piriformis syndrome include
1) A history of trauma to the area.
2) Difficulty, pain, or a stretch sensation in the buttock area with normal
walking.
3) Acute pain with stooping and lifting.
4) Tenderness to deep pressure (ei. sit on a tennis ball and roll it around your
buttock region).
5) Pain with a straight leg raise when lying on your back.
Your success in self-treating piriformis syndrome and sciatica is determined by their cause. For instance, if the piriformis reacted to a fall on your buttock, it can easily resolve with some deep tissue massage. However, I often find that the piriformis muscle is tight and painful due to a muscle tear of the piriformis or surrounding tissues. In this case, the piriformis muscle will continue to be tight and pinch the sciatic muscle until the torn muscle repairs itself, often taking months. The following exercises are intended to relax and lengthen the piriformis muscle to ease the pressure on the sciatic nerve. However, if the following exercises do not resolve the problem in 4-6 weeks, you should see your physical therapist or physician for a more thorough examination because there may be some biomechanical fault of the pelvis that is causing the syndrome.
27 The first exercise to release the piriformis muscle is to take a tennis ball and sit on it.
Roll around until you find a painful spot (feels like a deep bruise) and maintain constant pressure on the spot with the tennis ball until the pain resolves. This may take up to 2 minutes at a time. In the clinic, I use my hands or my elbow to find these tender points and release them. Usually, the first couple sessions are painful and time consuming and after you release the muscle it will continue to tighten up for a while. Each session will get easier and will consume less time, until the muscle no longer causes pain.
After the muscle has been released, it is a good idea to lightly stretch it out. Often times, sciatica is caused by a piriformis muscle that is just not very flexible. You should perform the piriformis stretch several times every day. When you stretch, you should only feel a light stretching sensation, you should not feel ANY pain.
PIRIFORMIS STRETCH
Setup: Begin by sitting in a chair with your right ankle on your left knee as shown.
28 Treatment: Press your right knee straight down towards the ground until you feel a light stretch in your buttock or hip region.
Exercise Parameters: Perform 3 repetitions of 30 seconds each leg.
BACK RX TREATMENTS
1. Soft Tissue Mobilization with Tennis Balls
This exercise is intended to release and relax tight muscles and muscles in spasm in the low back. If you have back pain that is caused by a round of golf, the pain is most likely due to tight muscles or muscles in spasm. This is an excellent treatment to relax those muscles. For better results, precede this treatment with 10 minutes of heat applied to the sore area (heat pack, hot tub, etc)
Setup: Place two tennis balls in a cotton sock and tie the end of the sock closed. Place the tennis balls in the middle of your low back. With the tennis balls placed on your back, lean up against a wall so that the tennis balls are being squeezed between your low back and the wall.
Action: From this position, bend and straighten your knees so that the tennis balls roll up and down your low back.
Treatment Parameters: Continue for 5 minutes and do this as many times during the day as you would like.
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2. Repeated Extension Progression
This treatment is intended to increase motion and treat disc bulges. If you experience INCREASING PAIN or an increase in radiating pain down your leg, discontinue this exercise. If you have difficulty with back pain in the morning, try this treatment in bed before you get up.
Picture 1: Next, prop yourself up on your elbows for 2 minutes.
Picture 2: Put your hands in a push up position. Press up, keeping your pelvis on the table. Hold for 1 second and return to lying flat on your stomach. Complete 12 repetitions.
No Picture: Finally, in standing place your hands on your hips. In this position, extend your back backwards. Hold for 1 second and repeat 12 repetitions. If you feel better after this exercise, repeat several times during the day.
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3. Abdominal Draw-in Progressions
Exercise #1
Exercise #2
The purpose of this exercise is to develop core and lumbar stability to reduce excess motion of the lumbar spine. This is especially important for golfers because we twist our backs so much during the golf swing.
Exercise 1: Begin by lying on your back with your knees bent up. Imagine that you have a small balloon under the small of your back. Draw your belly button in and flatten your low back as if you were trying to collapse the balloon.
Action Keeping your low back flat against the table, slowly extend one leg until it is straight. Bring that leg back up to the starting position and straighten your other leg.
Exercise parameters: Perform 12 repetitions with both legs.
Exercise 2: Begin by lying on your back with one leg bent up. Find the two bones on the sides of your pelvis.
Action: From this position, draw-in your belly button and flatten your low back against the table. Keeping your back flat, allow your
31 bent leg to rotate outward. The bones under your hands do not move even though your leg is moving.
4. Quadruped Arm and Leg Lifts
The purpose of this exercise is to strengthen your low back stabilizer muscles.
Setup: Begin on hands and knees. Keep your stomach tight by drawing in your belly button and keeping your low back as flat as possible throughout the exercise.
Action: Slowly lift one leg and the opposite arm. Repeat with other arm and leg.
Exercise Parameters: Perform 12 repetitions with each arm and leg.
Keys to Success: To check yourself on how well you are keeping your back straight, place a long golf club across your low back and perform the exercise without letting the club fall off.
5. Double and Single Leg Bridging
The purpose of this exercise is to stabilize the lumbo-pelvic area.
Setup: Begin by lying on your back with your knees bent and your feet flat. Draw in your belly button to stabilize your spine.
32 Action: Keeping your stomach tight, push through your feet to raise your hips off of the ground.
Exercise Parameters: Perform 15 repetitions.
Keys to Success: To progress this exercise, perform the bridges with only one leg.
6. Prone Planks (on or off knees)
The purpose of this exercise is to develop core stability. If you experience back pain with this exercise, try to pull your belly button in deeper. If you continue to have back pain, raise your buttocks up slightly. If you continue to experience back pain, discontinue this exercise and consult your physical therapist or physician.
Setup: Begin with knees and elbows on surface.
Action: Keeping stomach tight, your belly button drawn in, and back straight, raise hips off the surface to plank position.
Exercise Parameters: Hold 30-60 seconds trying to increase your hold time each time that you perform the exercise.
7. Side Planks
This is an excellent exercise to develop your deep core stabilizers.
33 Setup: Lying on your side with your elbows and knees touching the ground. Draw in your belly button to stabilize your spine.
Action: From this position, raise your hips off of the ground and hold this position. Make sure to keep your body in good alignment.
Exercise Parameters: Hold position for 30 seconds.
Keys to Success: For an additional challenge, perform this exercise with only your feet and elbows touching the ground. If this exercise bothers your elbow, try propping yourself up on your hands.
8. Side Ways Walkout Stabilizations
The purpose of this exercise is to train the multifidi, the deep lumbar stabilizer muscles of the low back.
Setup: Anchor the exercise band in a door at belly button height. Bend your knees, keep your back flat, and straighten your elbows so that you are holding the exercise band directly in front of you.
Action: Draw in your belly button to stabilize your spine. Maintaining this position, walk side ways 2-3 steps and then walk back.
Exercise Parameters: Perform 15 repetitions, both directions.
34 Keys to Success: Make sure to keep your hands directly in front of you with your arms straight.
9. Spinal Motion with Stabilization
This exercise is intended to stabilize joints that move too much (in older adults) and move or mobilize joints that are typically stiff.
Setup: In standing, find the top of your hip or pelvis bone. Place your hand firmly above this bone and press your hand firmly into your body to help stabilize the area.
Action: Finally, side-bend to the same side while you press your hand deeper into your side.
Exercise Parameters: Perform 15 repetitions, and repeat the other direction.
10. Heel to Butt Dynamic Stretch
The purpose of this exercise is to develop flexibility in the front of your hips and to improve posture and muscle balance.
35
Setup: Begin by lying on your stomach on the side of your bed with one foot off of the edge and on the floor as shown. Step as far forward as you can with the foot that is on the floor.
Treatment: From this position, bend the knee of the leg that is on the bed. You should feel a stretch in the upper thigh of that leg. Hold the stretch for 2-3 seconds and repeat.
Treatment Parameters: Perform 15 repetitions with each leg.
Chapter 3. Neck and Upper Back Rx
Nearly 70% of all Americans will experience neck pain or dysfunction some time during their lifetime and their chances increase with age. This does not bode well for golfers because the motion of the neck is critical for correct golf swing. If you are right handed, your neck rotates to the left as your shoulders rotate back in your backswing. The rotation required for a good backswing can be as great as 700! What happens if you are unable to rotate your neck fully? Bad things! If you do not have the correct amount of neck rotation, your head will move too much during your backswing. Effectively, a golf swing with this much head and neck movement is like trying to hit a moving target. You will never achieve consistency with this swing. As a result, if you are reading this and have limited neck range of motion, your first step should be to shorten your back swing or limit your shoulder rotation. You may lose some distance initially, but who cares about distance if you can’t hit the ball. As your neck flexibility improves with this program, you
36 will be able to rotate your shoulders more for added distance without losing ball contact consistency.
Red Flags and Reasons to See Your Physician
The cervical spine (neck) can be a very dangerous area to work with. As opposed to other areas in the body, there is a higher risk of serious injury at the neck. First of all, if you have experienced any head or neck trauma, such as a fall or vehicle accident, you need to stop reading and go to the emergency room immediately to be evaluated for a serious or potentially serious condition. This is no time to be the tough guy/girl, the consequences can be too severe.
In addition to trauma, you should see your physician immediately if you experience:
- Black outs or loss of consciousness
- Dizziness
- Tinnitus (ringing in your ear)
- Visual disturbances
- Difficulty Swallowing
- Constant, non-varying pain
- Changes in mental status or alertness
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Typical Causes of Neck Pain, Upper Back Pain, and Headaches
Although there are many causes of neck and upper back pain, there are only a few that you can successfully treat on your own. If in doubt, I strongly encourage you to schedule an appointment with your physician.
I. Posture
By far, the number one cause of neck pain and headaches that we see in our practice are caused by a forward head posture, rounded shoulders, and too much of a thoracic (mid- back) curve (thoracic kyphosis). This posture is often referred to or caused by Proximal
Crossed Syndrome. This is a clinical syndrome that refers to the change in muscle balances that is caused by years of bad posture. Due to the increased use of computers, this is becoming a more common problem. People who have worked in jobs where they are constantly stooped while standing or sitting are also at risk of developing Proximal
Crossed Syndrome. You can check your posture in the mirror or have a friend help you.
Generally speaking, proper alignment places your ears above the middle of your shoulders, above your hips. Although these points should make a straight line, your spine should also have a slight “S” curvature. Problems arise if your “S” curve is exaggerated where your lumbar spine is bowed too far forward or you have a large hump on your mid or upper back. If you find that your spine has these qualities, you probably also have a forward head where your ears are not lined up on top of the middle of your shoulders. Not only
38 does this position make it impossible for you to achieve the full neck rotation required for a good backswing, but also a forward head is blamed for numerous neurological and musculoskeletal impairments. An “S” curve is generally more common in women.
Men tend to exhibit a “C” curve (hunched over) or a flat back that has no curves at all. A flat back can lead to a lot of low back pain because your back depends on its natural curves for shock absorption. Instead of absorbing shock, every step you take transmits force directly to your low back and pelvis.
Finally, a third postural flaw that I will briefly mention is scoliosis. This is a condition in which the spine curves or bends to the left or right of your back. People with scoliosis generally know that they have it and have been diagnosed. In the 50 and over age group, women tend to have a slightly higher incidence of scoliosis due to spinal fractures from osteoporosis. Unfortunately, if you are over 50 and have scoliosis, conservative treatments generally do not cure but only slow the progression of the disease. I have been to some medical seminars in which groups have claimed success treating scoliosis but empirical evidence has not yet proven this to be the case. If you have scoliosis and have not seen a physical therapist, I encourage you to do so.
Ok, so if you are still reading this, I am going to assume that you need some postural work to overcome neck or upper back pain. I will warn you that there is no quick fix to correcting posture, however, it does not take big changes in posture to notice a big difference. To make postural changes, you will need to perform the following exercises
39 AT LEAST 2x’s per week and the more the better. These exercises are explained at the end of this chapter.
Exercise 1. Postural pinches 2. Resisted rows 3. Wall angels 4. Supine chin tucks 5. Nodding with cervical Retraction. 8. Upper traps stretch with arm assist 9. Cervical side bend stretch with front arm pull
II. Thoracic Outlet Syndrome (TOS)
TOS is a clinical syndrome in which neural structures (nerves) and/or vascular structures (arteries / blood flow) are compressed and cause symptoms such as arm and/or hand numbness, tingling, and/or radiating pain. Nerves of the brachial plexus as well as the subclavian artery can be impinged upon in several places as they leave your neck and move down towards your armpit. When I see a patients with TOS, they usually report symptoms such as their arms “falling asleep” when they are sleeping or numbness or tingling when reaching to the side overhead (abduction). Patients have also reported
“coldness,” an electric shock feeling, numbness, and/or tingling down the inside of the arm to the pinky and ring finger.
TOS has several causes, however, the best treatment is to read the preceding section and improve your posture. If you checked your posture and it is poor, and especially if your head posture is too far forward or if your shoulders are rounded forward, there is a
40 good chance that posture is now causing TOS. However, before beginning a corrective exercise program, it is important that you see your physician to evaluate the cause of symptoms.
NECK AND THORACIC TREATMENTS
1. Scapular Pinches
The purpose of this exercise is to correct poor posture and aligns the spine in the most pain free position.
Setup: Begin in standing with your arms hanging loosely by your side.
Action: Pull your shoulders back and downward as if you were trying to put them in your back pocket. You should feel the muscles between your shoulder blades pushing up against each other or pinching. Hold this position for 5 seconds.
Treatment Parameters: Perform 3 sets of 12 repetitions. Ideally, we would also like to perform this exercise throughout the day as you go about your normal routine (take a quick break at your desk and perform 4-5 reps, for example).
Keys to Success: It is very important that you pull your shoulders back and DOWN. Do not let your shoulders shrug upwards
41 2. Resisted Rows
The purpose of this exercise is to correct muscle imbalances that result in poor posture. Poor back and neck posture is the primary cause of upper back and neck pain and headaches.
Setup: Begin with exercise band anchored to a door at chest level. Loop the exercise band through the door anchor loop so that you can hold each end of the band with each hand.
Action: Slowly bend elbows and pull back by squeezing shoulder blades together behind you.
Exercise Parameters: Perform 1-3 sets of 20 repetitions.
Keys to Success: Make sure to keep your shoulders down as you pull back.
3. Wall Angels
The purpose of this exercise is to build strength and create the proper strength and length muscular balance between your back and chest muscles.
42 Setup: Begin by standing with your back flat against a wall and your arms setup as shown. Your feet should be about one foot away from the wall so that you are leaning back against the wall slightly.
Action: Keep your elbows and wrists back as close to the wall as you can, raise and lower your arms as shown (like performing a snow angel).
Treatment Parameters: Perform 3 sets of 12 repetitions.
Keys to Success: Keep your neck muscles relaxed. Most of our patients with neck and back pain are not able to flatten their arms against the wall behind them. Just do the best you can and you should see some good flexibility improvements.
4. Supine Chin Tucks
This exercise is designed to both promote proper bony alignment and to improve the length and strength muscular balance that will help with good posture.
Setup: Begin by lying down on your back with a small towel rolled up and placed underneath the curve of your neck.
Action: Keeping the back of your head on the table, tuck in your chin so that you are pushing down on the towel with your neck.
Treatment Parameters: Perform 1-3 sets of 20 repetitions.
43
Keys to Success: Discontinue this exercise if it causes a significant increase in pain, dizziness, nausea, etc. Also make sure that the back of your head does NOT lift up off of the table.
5. Nodding with Cervical Retraction
This exercise is designed to stretch the upper most cervical muscles which tend to become short and tight in people that work on computers or sit at a desk for long periods of time.
Setup: Begin in sitting or standing.
Action: First, draw your chin back like you did in the previous exercise. Next, maintaining this position, nod your head forward until you feel some light tension behind your uppermost neck.
Treatment Parameters: Do as many of these as you can fit into your day. At a minimum, perform 3 sets of 20 repetitions.
Keys to Success: Discontinue this exercise if it causes a significant increase in pain, dizziness, nausea, etc.
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6. Self-Traction Technique (Mulligan)
The purpose of this technique is to lightly separate the vertebra or create space in between the holes (foramen) where nerves from the spinal cord leave through. This technique will help if you bend your neck forward and have pain or stiffness at the end of the motion. Do not perform this technique if it causes pain.
Setup: Begin in a seated or standing position. Make a fist with your left hand and place it under your chin and on top of your uppermost breastbone.
Action: Place your right hand behind your head and pull your head forward and over you left fist.
Treatment Parameters: Hold stretch for 10 seconds and repeat 3 times.
Keys to Success: You should be able to bend your head forward with more ease after this treatment. If this technique does not help after performing it for a couple of days, discontinue because it is not helping you. Remember, there should be no pain with this technique.
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7. Extension Mobilization
The purpose of this technique is to restore extension range of motion, or tilting your head backwards. You will need a small towel for this technique.
Setup: Hold the corners of the same side of the towel with both hands. Place the edge of the towel straight across the back of your neck at the point that you feel is most stiff or painful when you tilt your head backwards.
Action: Pull on the ends of the towel in the direction of your eyeballs as you tilt your head backwards. As you tilt your head backwards, your hands should be pulling the towel up with the motion of your head.
Treatment Parameters: Perform 6 repetitions.
Keys to Success: If your motion is restored and the pain relieved, you have found the correct exercise. If no change is noted, move the towel up or down to a different position and re-try the treatment. After you have tried every level of your neck with the towel and you still do not find relief, than this treatment will not help you.
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8. Upper Trapezius Stretch with Arm Assist
The purpose of this stretch is to lengthen and relax muscles in the neck that commonly cause tightness, pain, and loss of motion. Discontinue this stretch if you experience dizziness or visual disturbances.
Setup: Begin in sitting with you left hand on top of your head and your right hand behind your back.
Action: With your left hand, lightly pull your head to the left and downwards until you feel a light stretch in the back of you neck on the right. From this position, reach further behind your back with your right hand.
Treatment Parameters: Hold stretch for 30 seconds and repeat, AT LEAST, 3-4 times per day.
9. Cervical Side bend Stretch with Front Arm Pull
The purpose of this exercise is to stretch your front and lateral neck muscles that can often cause local and radiating pain if too tense. Discontinue stretch if you experience dizziness or visual disturbances.
47
Setup: Begin in sitting with your right arm pulled across your body as shown.
Action: From this position, side bend or tilt your neck to the left until a light stretch is felt.
Treatment Parameters: Hold stretch for 30 seconds and repeat at least 3 times/day.
Chapter 5. Shoulder Rx
Unlike other sports, people often start playing golf at middle age and continue to enjoy it for several more decades after that. While I think that it is great to be able to continue to be active and compete in a sport later in life, the body becomes more susceptible and sensitive to wear and tear. Besides the knee joint and the low back, the shoulder joint tends to be the most commonly injured body part in people as they age. The shoulder is so important in the golf swing that any damage to the joint can lead to an early exit from the game you love. This is the case with one of our local PGA teaching professionals. A couple surgeries to his left shoulder for rotator cuff injuries and he can no longer follow through properly, causing a loss in distance and tendency for a nasty hook.
He has several decades of healthy living left, but his golfing days are probably gone.
Unless you plan on retiring to a career in gardening and housework, take heed of this professional golfer’s story and take some preventative measures so that you don’t end up needing major surgery!
48 Differential Diagnosis and Non-Orthopedic Causes of Shoulder Pain
In my home state of Idaho, patients can come to physical therapy without having to get a referral from their physician, called “direct access.” Since physical therapists are essentially musculoskeletal specialists, we are well equipped to discover and treat musculoskeletal injuries and many patients can avoid the more costly trip to the doctors office. However, since we are able to be the primary care providers for patients, we have to be much better at determining when a musculoskeletal or nervous tissue is not causing pain and dysfunction. I mention this in our shoulder section because many of the internal organs can refer pain to the shoulder. The heart often refers to the left shoulder and arm in men but refers pain to the right shoulder and central chest in women. Issues stemming from the gall bladder, liver, or the lungs can also cause right shoulder pain. As a result, if you experience shoulder pain that does not get worse or get better with any movement and is persistent for greater than 3 weeks, you should call your physician for an evaluation.
Typical Causes of Shoulder Pain
I. Impingement Syndrome and Rotator Cuff Injuries II. Instability III. AC Joint Sprain or Separation IV. Biceps Tendonitis V. Frozen Shoulder Syndrome (Adhesive Capsulitis)
I. Impingement Syndrome and Rotator Cuff Injuries
49 Rotator cuff injuries are included with impingement syndromes because they often cause the impingement. In addition, training the rotator cuff is typically the best course of action to relieve an impingement regardless of what originally caused the impingement.
When a person raises their arm, two bones in the shoulder (acromiom and glenoid) come closer to each other. If these bones come too close together, they can compress pain sensitive soft tissues in the shoulder causing a “pinching” sensation of pain. This is called an impingement. The four muscles of the rotator cuff play a large part in maintaining the space between these two bones. If the rotator cuff is torn or weak, you will likely have or soon develop an impingement that is called Subacromial Impingement Syndrome. This is a condition in which you will have shoulder pain when lifting objects above the shoulder, reaching across your body, and swinging a golf club.
The course of treatment depends on how your symptoms came about. Subacromial
Impingement Syndrome can come about by a variety of pathways. A traumatic injury can result in a rotator cuff tear and subsequent impingement because the rotator cuff can no longer function properly. If you have had such an injury and it does not get dramatically better in a couple of weeks, you should contact your health care provider for more in depth evaluation. But please follow this rule: Always undergo physical therapy or a home program (such as the one provided in this book) if you have strained your rotator cuff or injured your shoulder. I evaluate many patients who sprained their rotator cuff 6…9…and even 12 months prior to undergoing treatment because they were not properly referred to
50 physical therapy. The result is a weak, underperforming rotator cuff that has led to a severe impingement syndrome, bursitis, tendonitis, muscle wasting, instability, bone spurs, internal scarring and adhesions, etc. Sadly, most of the patients with a shoulder this bad will never regain full function, not even with surgery. So please ask for a referral to a physical therapist as soon as possible when you visit your physician. When shoulder injuries are treated early, the success rate is extremely high.
Aside from a traumatic injury, an impingement syndrome and rotator cuff injures can be also be caused by wear and tear and overuse. This is more commonly seen in adults over 40 years old. If you have the symptoms of an impingement syndrome, and do not remember ever specifically injuring the shoulder, this case scenario may describe your shoulder. If this is the case, you can follow the treatment plan that we describe below.
Follow this plan for 6 weeks and if your shoulder gets worse or does not improve, contact your health care provider for further evaluation. Before beginning this treatment plan, please read the previous section on differential diagnosis and non-orthopedic causes of shoulder pain.
Please perform the following exercises listed at the end of this chapter daily:
Exercise: 1. Shoulder walk backs.
Please perform the following exercises listed at the end of this chapter 3 timer per week: Exercises: 2-8
**Discontinue or limit any exercise that causes significant discomfort.
51 II. Shoulder Instability
In adults over 50, the cause of shoulder instability can be either due to a fall in which the shoulder dislocates or, more commonly, due to deconditioning over time in which the mechanisms supporting the shoulder joint can no longer function adequately.
The joint can become involved in a self-perpetuating cycle of more instability → less use
→ more shoulder dysfunction → and back to more shoulder instability. Although the following exercise will help to stabilize the shoulder, your physician and physical therapist should always evaluate you first. No home program can take the place of hands on treatment from a skilled professional.
To help stabilize the shoulder, complete the following exercises listed at the end of this chapter 3 times per week: 2, 3, 7, 8.
III. Biceps Tendonitis
Irritation of the biceps tendon occurs more often as a secondary condition related to an impingement syndrome. The biceps tendon is a band of tissue that can be felt on the front part of the shoulder. If you take your fingers and rub across your shoulder sideways, the tissue that you are “flipping” over is the biceps tendon. If this tendon is more tender than the same area on your other shoulder, you may have biceps tendonitis. Biceps tendonitis is best treated with ice, rest, and some light cross-friction massage that you can perform on yourself. Reaching behind your back, repetitive or heavy lifting is cautioned against as these may exacerbate symptoms and prolong the tendonitis until the condition
52 becomes chronic. If symptoms do not resolve in 4-6 weeks, you should be evaluated by your physician to avoid chronic and degenerative changes to the biceps tendon.
IV. Frozen Shoulder Syndrome (Adhesive Capsulitis)
Of all the orthopedic conditions that we see as physical therapists, frozen shoulder is the most over diagnosed and incorrectly diagnosed. There are several possible causes of frozen shoulder; the most commonly sited being an inflammatory autoimmune mechanism in which your own immune system attacks your shoulder. Frozen shoulder is more common in females, between the ages of 40-60, have diabetes, undergone prolonged immobilization (used a shoulder sling), have thyroid disease, or have experienced a stroke or heart attack. Frozen shoulder usually affects the non-dominant arm. Frozen shoulder can be defined as the spontaneous onset of gradually progressive shoulder pain and eventually severe limitation of movement in ALL planes of movement. It is often wrongly blamed when a patient has restriction of movement in only one plane of motion, such as reaching overhead. Ever since the phrase “frozen shoulder” was coined in the 1930’s, the cause and mechanism has largely remained a mystery to this day.
What we do know is that frozen shoulder is typically a self-limiting disease, it mostly resolves itself naturally. This process of increasing pain and stiffness to self- healing can last anywhere from 6 months to 10 years but the average is between 1 and 3 years. Your best bet to managing frozen shoulder is to first understand that it typically
53 passes through 3 sequential phases, “freezing,” “frozen,” and “thawing,” and that each phase needs to be managed differently. You will find many differing opinions on how to treat each phase, but we will look at what the latest research has found.
First, you should see a physical therapist for aggressive treatment for at least one month following diagnosis. This is because true frozen shoulder is very rare and often wrongly diagnosed. If you see improvements in the first month of physical therapy, you probably do not have frozen shoulder and should continue treatment until you regain shoulder movement without pain. However, if physical therapy does not improve symptoms or function, you may truly have frozen shoulder and should move to the next phase of management.
The next phase of management is having a physical therapist prescribe a home regimen to allow the natural progression of frozen shoulder through the “freezing” stage without making it worse or increasing inflammation. During this stage you may experience persistent pain in the shoulder and a progressive loss of range of motion.
Treatment should include gentle range of motion exercises using an over the door pulley, very gentle stretching, and no strengthening, lifting, pulling, pushing, etc. You should also talk to your physician concerning anti-inflammatory medications and corticosteroid injections. Early corticosteroid injections have been shown to be very effective in limiting the long-term effects of frozen shoulder and even improving healing time. This phase typically lasts 6 months, although it can last much longer. You should see a physical
54 therapist and/or physician for monthly follow up visits to determine when your shoulder has progressed past the “freezing” stage to the “frozen” stage.
Treatment in the “frozen” stage is very similar to the prior phase. You may have less pain although you will still have a very stiff shoulder. You need to continue to be careful not to do too much with your shoulder and you should not raise your arm above shoulder height using your own muscles. This can lead to the development of a shoulder impingement. Continue to perform your exercises and you can stretch a little more aggressively as long as you feel NO PAIN. If you are stretching into the pain, you may be stimulating an inflammation response, which will delay your progress. If your pain has largely subsided, you can begin to see your physical therapist on a regular basis. The
“frozen” stage lasts 8 months on average.
Finally, you know that you have reached the “thawing” stage when your pain at rest and during sleep has largely subsided and you are beginning to regain small amounts of motion. This is the critical phase when you should be seeing your physical therapist regularly and should consult your physician about corticosteroid injections. Stretching should be more aggressive, your physical therapist will help to mobilize the joint, and you can begin to lift weights. When lifting weights, you should only lift lightweights light enough that you can perform 50 or more repetitions. This will help develop the tensile strength of your tendons and will limit any joint irritation.
55 In some cases, patients do not respond well to physical therapy aimed at recovering range of motion. In these rare cases, you need to discuss surgical options with your physician. However, this should be your last resort because surgical manipulation of the shoulder can cause further injury to the shoulder.
SHOULDER TREATMENTS
1. Shoulder Walk backs
The purpose of the exercise to promote proper tracking of the shoulder in its joint. If you have pain reaching overhead, this can be a beneficial exercise for you. This exercise is great for rotator cuff injuries and shoulder impingements, but is not good for AC Joint separations.
Setup: Begin by finding a very stable surface at or just below your belt line in height. Tables and counters usually work best. Place the hand of the involved shoulder on the edge of the surface. Make sure that the surface is not slippery and that you have a good hold.
Action: Keeping your elbow straight and your shoulder back and shoulder blades pinched together behind you, slowly walk back as far as you can comfortably.
Exercise Parameters: Perform this exercise for 2 minutes.
56 Keys to Success: If this exercise increases your symptoms for more than one minute, discontinue and call your health care provider.
2. External Rotation with Exercise Band
The purpose of this exercise is to rehabilitate and strengthen the rotator cuff. These muscles are very important for shoulder stability and proper tracking of the shoulder in the joint.
Setup: Anchor one end of the exercise band to a door at waist height. Grasp the exercise band with the hand that is furthest from the door. In addition, you should roll up a small hand towel and place it between your elbow and the side of your body.
Action: Keeping elbow in towards your side, pull exercise band across the body by rotating your arm.
Exercise Parameters: Perform 1-3 sets of 20 repetitions.
Keys to Success: Note: make sure that the angle at your elbow does not change (do not bend or straighten the elbow throughout the exercise).
57 3. Internal Rotation with Exercise Band
The purpose of this exercise is to rehabilitate and strengthen the rotator cuff. These muscles are very important for shoulder stability and proper tracking of the shoulder in the joint.
Setup: Anchor one end of the exercise band to a door slightly above waist height. Grasp exercise band with the hand that is closest to the door. In addition, you should roll up a small hand towel and place it between your elbow and the side of your body.
Action: Keeping elbow in towards your side pull exercise band across the body by rotating your arm inwards.
Exercise Parameters: Perform 1-3 set of 20 repetitions.
Keys to Success: Make sure that the angle at your elbow does not change (do not bend or straighten the elbow throughout the exercise). Keep your shoulders back, do not let your shoulders translate forward with the movement.
4. Scaption (moving in the plane of the scapula or “shoulder blade”)
The purpose of this exercise is to strengthen key muscles around the shoulder and shoulder blade.
Setup: Begin in standing with good posture.
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Action: With arm straight and thumb up, raise arm overhead at a 450 angle while keeping your shoulders held down.
Exercise Parameters: Perform 20 repetitions. You can use dumbbells or other weighted objects for more resistance as long as you maintain good posture and the exercise does not cause shoulder pain.
Keys to Success: Perform exercise in front of a mirror to check for shoulder height symmetry. Do not raise your arm above your shoulders unless you can do it with equal shoulder height and without pain.
5. Seated Press Ups in a Chair with Arm Rests
The purpose of this exercise is to strengthen the lower scapular (shoulder blade) stabilizing muscles. These are very important muscles for correct shoulder motion.
Setup: You will need a chair with an armrest for this exercise.
Action: Press up by straightening your elbows and depressing shoulders to lift your body up. Press your upper body towards the ceiling as far as you are able to without sacrificing correct mechanics.
Exercise Parameters: Perform one set of up to 20 repetitions.
Keys to Success: You can place your feet under you to assist the motion or extend your legs out in front of you to make the exercise more difficult. Discontinue if this increases abnormal shoulder pain.
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6. Push-Up Plus on Table
This purpose of this exercise is to strengthen the serratus anterior muscle that is an important muscle for shoulder blade control.
Setup: Begin by leaning on table in a push-up position with your elbows locked straight.
Action: Press forward with shoulders, pushing yourself as far away from the table as you can. Then return to your starting position and repeat.
Exercise Parameters: Perform one set of up to 20 repetitions.
Keys to Success: If this exercise cause back pain, draw in your belly button to stabilize your spine and focus on keeping your back flat.
7. Resisted Rows
The purpose of this exercise is to improve posture and stabilize the shoulder posteriorly and promote proper mechanics of the shoulder.
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Setup: Begin with exercise band anchored to a door at chest level. Loop the exercise band through the door anchor loop so that you can hold each end of the band with each hand.
Action: Slowly bend elbows and pull back by squeezing shoulder blades together behind you.
Exercise Parameters: Perform 1-3 sets of 20 repetitions.
Keys to Success: Make sure to keep your shoulders down as you pull back.
8. Horizontal Shoulder Abduction
The purpose of this exercise is to stabilize the shoulder and pull it into correct alignment.
Setup: Begin by anchoring the exercise band in the door at shoulder height. Stand with your side towards the door and hold the exercise band in front of you with a straight arm.
Action: Keeping elbow straight, slowly pull band across your body in a wide arc. Focus on squeezing your shoulder blade towards your spine as you perform the exercise.
Exercise Parameters: Repeat 20 slow and controlled repetitions.
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Chapter 6. The Wrist and Hand
The interplay of structures in the wrist and hand allow for great functional dexterity and precision while a delicate balance. The radius and ulna in the forearm join the 27 bones in the hand to create this finely tuned architecture. Any disruption in the structure or its dynamic control will results in breakdown and pain that can hold you back from your game. A joint is created whenever any two bones come together resulting in a multitude of articulations. A complex network of ligament and muscles holds this series of links together. Twenty four muscles come down the forearm to join the 19 internal to the hand to enable broad range of tasks from fine control in writing to mass grasp of lifting heavy boxes. The muscles are controlled by three main peripheral nerves that branch out to each active unit as communication lines. Each piece of this system must work together as a well conducted, finely tuned orchestra of musicians to yield the symphony that is wrist and hand function.
Use of the wrist and hand in your golf game mostly involve grasping the clubs and controlling your clubface. The difference in a good shot and a great swing can be made in the wrist and hand. This complex is the last chance your body has to influence the forces coming toward the ball prior to impact.
There are six injuries that will occur in the elbow, wrist, and hand in complex most commonly in golf. They are DeQuervain’s Syndrome, Hammate fracture, Carpal Tunnel
Syndrome, Golfer’s elbow, Tennis elbow, and injury to the Triangular Fibrocartilage
62 Complex (TFCC). We will discuss these in detail next along with what you can do to prevent them.
I. DeQuervain’s Syndrome
This is a syndrome of inflammation in the tendons and the synovium of the tendon sheath that surrounds the two tendons that control the thumb movement. It usually occurs as a result of repetitive sliding of the tendons on the thumbs side of the wrist. It is named after a Swiss surgeon who first identified it as a disorder and is most commonly associated with using a computer keyboard, as this constantly requires a repetitive up and down motion of the thumb.
Symptoms include pain and swelling on the thumb side of the wrist especially with gripping and possible numbness on the pack of the thumb. An easy test to determine if your pain is from this syndrome is called the Finkelstein’s test. To test yourself place the thumb in a closed fist and tilt the hand towards the little finger. If pain occurs at the wrist below the thumb it is likely you have De Quervain’s tenosynovitis. Most cases are self- limiting and resolve in a year on their own. However splints may help your comfort but have not been shown to accelerate the course of the syndrome.
Prevention includes proper ergonomic set up if you work on a computer, often taking stretch and rest breaks during the day (see stretching exercises at the end of this section), gradually increasing your activity level if you are starting new exercises or
63 programs, and proper golf equipment and, of course, excellent golf mechanics in your swing.
II. Hook of the Hammate Fracture
The hammate is a bone in the base of the palm on the little finger side. It is usually injured when hitting something hard during a swing such as a rock, root, or too much ground. The force transfers up the club and impacts the butt of the club into the ulnar side
(pinky side) of the hand. If you grip the club too far into the palm your hammate is more vulnerable.
This type of fracture will lead to a dull ache in that area of the hand. It is not usually seen in a standard hand X-ray but requires a special carpal tunnel or even a CT scan or
MRI to diagnose.
Prevention is the key to this injury. Make sure you have proper club length, proper grip size, and utilize and proper grip with your hands. Make sure you grip the club more in the fingers, similar to how you would grip when doing a pull-up on a bar.
III. Carpal Tunnel Syndrome
Carpal tunnel Syndrome is a condition where the median nerve is compressed at the wrist. It is the most common of the repetitive strain injuries. You know, like gripping and swinging a golf club dozens of times after having spent the week gripping to write or type on a keyboard. This can cause symptoms like loss of grip stability, pain, tingling, and numbness in the thumb and first two fingers and a feeling of coldness in the hand.
64 The median nerve runs through the wrist in s tunnel that is surrounded by bones on three sides and the flexor retinaculum as the ceiling. Along with the nerve sit many tendons that work in the hand. The nerve can be compressed by inflammation or swelling in the tunnel. Usually the symptoms show up first when you are trying to sleep. Many times people will blame their sleeping position on this and, thus, modifying the sleeping position is usually a good start to treatment. However, if changing sleeping positions does not change your symptoms, you may need to consider the possibility of a carpal tunnel problem. If left untreated the symptoms often progress to intense pain and restricted hand function. If these symptoms sound familiar to you, pay your physician a visit to have it diagnosed.
There are several treatment options to address and treat this condition. They include wearing an immobilizing brace or splint, a local steroid injection (from your physician), soft tissue therapy, activity modification with proper ergonomics, and as a last resort, some recalcitrant cases require carpal tunnel release surgery.
Proper wrist care is important to make sure you do not end up dealing with this difficult condition. Taking breaks often during repetitive tasks, gentle stretching (see stretches at the end of this chapter), and even putting ice on your wrists after activities can be helpful for prevention.
VI. Triangular Fibrocartilage Complex (TFCC)
65 One of the most common and serious wrist injuries is damage to the TFCC. This structure is a complex made up of ligaments and cartilage that stabilize the forearm at the wrist. Injuries occur from ulnar overload such as when the left hand fully releases the club though impact. It can become injured from either trauma (hitting a hard surface on a swing) or over time with improper swing mechanics. Swing faults such as “Casting”,
“Over the top”, and “heavy divots” are usually the culprits. To test you TFCC place your wrist in ulnar deviation (little finger toward the side of your forearm), and apply compression like pushing down into a table. If this provokes pain on the little finger side of your wrist you may need to have this checked out by your medical professional.
V. Tennis Elbow (lateral epicondylosis)
A large number of muscles come together to attach at the lateral epicondyle of the humerus, which is the bony knob located on the outside of your elbow. This includes all the extensor muscles of the wrist and fingers. In particular the Extensor Carpi Radialis
Brevis, and the Supinator are troublemakers here. There is a tendency to overuse these muscles and they will lose flexibility as a result. When they are over loaded micro tearing will result. Eventually this leads to the pain and problems commonly called Tennis Elbow.
Symptoms of this condition include the outer part of the elbow being tender to touch, pain radiating down the back of the forearm, movements of the elbow hurt especially lifting, and with this condition the pain usually subsides overnight. Gripping objects, such as a golf club, can aggravate it. If left untreated, these symptoms can
66 continue to increase in severity of pain as well as lead to increasing functional limitations including inability to play golf. Recognizing it early and working to reverse the degenerative change in the tendons is very important. The key is to reduce the stress applied to the extensor tendons, which pull on the bone.
This most often occurs in the lead arm for golfers. Ironically, Tennis elbow will occur up to seven times more often in golfers than Golfer’s elbow. Often this is due to swing faults such as cupping of the lead wrist in combination with chicken winging the elbow on the same arm during impact. This serves to increase the tensile forces on the lateral epicondyle, which can lead to physical breakdown.
Often a tennis elbow brace will provide relief and is a good starting point for self- treatment. It wraps around the forearm and takes pressure off the muscle attachments at the elbow. Your sleeping position may also play a role this developing tennis elbow.
Make sure you are not sleeping on the affected side and keep that arm below shoulder level all night.
Make sure you have your grip size checked on your clubs. If the grips are too big for your hands you may be overusing the muscles over time and increasing your pain. Be aware of your grip, you may be gripping too hard on the club due to poor grip position.
Proper sequencing of your swing is also important so that you are not compensating with the arms and hands for what the rest of the body is lacking in motion. Also, make sure you follow a good warm up routine (such as the ADG Dynamic Warmup) prior to playing a
67 round or hitting at the range. The exercises at the end of this section will also make for a good warm up program for the wrist.
VI. Golfer’s Elbow
Medial epicondylitis, commonly referred to as Golfer’s elbow, is usually caused by overuse of the tendons on the inner part of the arm. However, it can also be caused by poor sleeping position, for example sleeping with your arm elevated or with your hand under your head or pillow. Try strapping your arm to your side with a belt while you sleep if this significantly helps your symptoms.
Golfers elbow is basically a strain of a group of muscles called the flexor-pronator group in the forearm. This strain is often caused by improper swing mechanics or hitting a root or rock. Symptoms include tenderness to touch on the inner part of the elbow, elbow pain radiating down the front side of the forearm, lifting a heavy object, and the pain usually subsides overnight. If this is not treated appropriately, the pain will likely increase in intensity and severity and may become serious. If these symptoms match what you are feeling, get an evaluation by your medical professional.
As you can see in this chapter, while your hand is complex and fragile, with proper care it can work for you and continue to perform well for you throughout your entire golf career. As the saying goes, an ounce of prevention is worth a pound of cure. Develop the habit of a good dynamic warm up including the wrist and hand prior to, and even in the middle of your golf rounds. By keeping these few tips in mind you will be assured that
68 potential wrist and elbow issues related to golf will not hinder your enjoyment or limit your golf game.
1. Soft tissue mobilization for pain relief
The purpose of this treatment is to release scar tissue, muscle and tendon adhesions, and re-align tissue correctly. If this treatment causes discomfort, then it most likely IS AN EFFECTIVE TREATMENT for you. If it is painless, discontinue unless it relieves other symptoms.
Setup: You will need a clean golf ball and some lotion for this treatment. Begin by laying your arm on a firm surface with your palm down. Rub lotion into the area that you will be treating.
Treatment: Holding the golf ball in your other hand, rub the golf ball along the painful areas of your forearm firmly. If your find a really tender spot, the best way to treat it is to hold the golf ball on it firmly for 90 seconds or until the pain subsides.
Treatment Parameters: Continue for 5-10 minutes.
Keys to Success: Massage the area in all directions, especially cross ways (cross friction massage).
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2. Six Way Wrist Exercises for Strength and Stability
2A. Wrist Extension
Setup: In sitting position, step on one end of the exercise band, anchoring it to the floor. Grasp the other end of the exercise band with your hand palm down.
Treatment: Begin with your wrist bent towards the ground, then flex your wrist upwards as shown in the picture.
Treatment Parameters: Perform 20 repetitions.
Keys to Success: When you begin this exercise, perform the motion WITHOUT the exercise band. If you can complete this without pain, you can progress to using the exercise band. The key here is that the motion should be pain free (except for normal muscle pain).
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2B. Wrist Flexion
Setup: In sitting position, step on one end of the exercise band, anchoring it to the floor. Grasp the other end of the exercise band with your hand palm up.
Treatment: Begin with your wrist bent towards the ground, then flex your wrist upwards as shown in the picture.
Treatment Parameters: Perform 20 repetitions.
Keys to Success: When you begin this exercise, perform the motion WITHOUT the exercise band. If you can complete this without pain, you can progress to using the exercise band. The key here is that the motion should be pain free (except for normal muscle pain).
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2C. Radial Deviation
Setup: In sitting position, step on one end of the exercise band, anchoring it to the floor. Grasp the other end of the exercise band with your thumb side of your hand up.
Treatment: Begin with the pinky side of your wrist bent towards the ground, then flex the thumb side of your hand upwards as shown in the picture.
Treatment Parameters: Perform 20 repetitions.
Keys to Success: When you begin this exercise, perform the motion WITHOUT the exercise band. If you can complete this without pain, you can progress to using the exercise band. The key here is that the motion should be pain free (except for normal muscle pain).
2D. Ulnar Deviation
72 Setup: In sitting position, step on one end of the exercise band, anchoring it to the floor. Grasp the other end of the exercise band with your palm down.
Treatment: With your palm facing down, bend your wrist towards the pinky side of your hand.
Treatment Parameters: Perform 20 repetitions.
Keys to Success: When you begin this exercise, perform the motion WITHOUT the exercise band. If you can complete this without pain, you can progress to using the exercise band. The key here is that the motion should be pain free (except for normal muscle pain).
2E. Forearm Pronation
Setup: In sitting position, step on one end of the exercise band, anchoring it to the floor. Grasp the other end of the exercise band with your palm down.
Treatment: From this position, rotate your wrist and forearm so that your palm is facing up. Return to the starting position.
Treatment Parameters: Perform 20 repetitions.
Keys to Success: When you begin this exercise, perform the motion WITHOUT the exercise band. If you can complete this without pain, you can progress to using the exercise band. The key here is that the motion should be pain free (except for normal muscle pain).
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2F. Forearm Supination
Setup: In sitting position, step on one end of the exercise band, anchoring it to the floor. Grasp the other end of the exercise band with your palm up.
Treatment: From this position, rotate your wrist and forearm so that your palm is facing down. Return to the starting position.
Treatment Parameters: Perform 20 repetitions.
Keys to Success: When you begin this exercise, perform the motion WITHOUT the exercise band. If you can complete this without pain, you can progress to using the exercise band. The key here is that the motion should be pain free (except for normal muscle pain).
3. Gripping
Setup: Comfortably rest your forearm on a table surface. Grasp a tennis ball in your hand.
Treatment: Gently squeeze the tennis ball and hold for 5 seconds. Relax for 2 seconds and repeat.
74 Treatment parameters: Perform 10-12 repetitions without pain.
Keys to Success: Squeeze the ball at approximately 80% of your maximum strength at first to ensure that the exercise does not cause pain. You may then increase to 100% of your maximum strength.
4. Wrist Extension Stretch
Setup: Rest your forearm on a table surface with your palm down.
Treatment: With your opposite hand, grasp the palm and slowly pull your hand back while keeping your forearm on the table. Once you feel a pain-free stretch underneath your forearm, hold the position.
Treatment Parameters: Hold stretch for 20-30 seconds. Repeat stretch up to 3 times.
5. Wrist Flexion Stretch
Setup: Rest your forearm on a table surface with the palm facing UP.
75 Treatment: With your opposite hand, grasp the back of your palm and slowly bend your wrist towards your forearm. Once you feel a pain-free stretch on the back of your wrist, hold the stretch.
Treatment Parameters: Hold the stretch for 20-30 seconds. Perform the stretch up to 3 times.
6. Triceps Stretch
Setup: Begin in standing or sitting and place raise your right arm up to the ceiling with your elbow bent.
Treatment: With your left hand, push your right elbow backwards until a stretch is felt in triceps muscle (opposite side of your arm as your biceps muscle).
Treatment Parameters: Hold stretch for 20-30 seconds x 3 sets with both arms.
Keys to Success: If this position is too difficult, prop your elbow up against a wall instead of grabbing with your hand. Lean into the wall for a good stretch.
7. Biceps Stretch
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Setup: Begin in standing or sitting with your right arm extended forwards with your palm facing up.
Treatment: Use your left hand to grasp the fingers of your right hand and pull them backwards until a stretch is felt on the topside of your elbow…just below the biceps muscle belly.
Treatment Parameters: Hold stretch for 20-30 seconds x 3 sets with each arm.
6. Nerve Glides
In my practice as a physical therapist, many times we have a patient that is diagnosed with “golfers elbow” or “tennis elbow.” In actuality, many of these patients have nerve entrapments. A nerve entrapment occurs when the movement of the nerve is restricted. This condition may have many causes but is most often caused by soft tissue binding the nerve up, like spider webs. These are treated with nerve glides, also called nerve “flossing.” Below, we demonstrate how to glide the 3 primary nerves that or often the culprits of this condition in the order of their frequency. Note: the glide that causes the most discomfort is typically the nerve that is being restricted.
A. Radial Nerve Glides
Setup: Begin in standing with your arms relaxed at your side.
Treatment: 1. Begin with involved arm at your side. 2. Drop your involved shoulder. 3. Flex your wrist (palm up) and rotate your arm so your fingers are pointing away from your body. 4. Tilt your head away from the involved side. 5. Raise your arm away from your
77 body. Perform steps in succession until you feel a stretch or a light “stingy” sensation.
Treatment Parameters: Hold for 5 seconds and repeat 10 repetitions.
B. Median Nerve Glides
Setup: Begin in standing with your involved arm up and your palm flat against the ball at shoulder height.
Treatment: Keeping your elbow straight, rotate your body away from the wall until you feel either a stretch or a light “stingy” sensation which is your nerve being stretched.
Treatment Parameters: Hold for 5 seconds and perform 12 repetitions.
Keys to success: Perform this exercise slowly and do not over stretch.
C. Ulnar Nerve Glides
Setup: Begin in standing.
Treatment: Start with arm out to side with elbow straight and palm toward the floor, bend elbow to bring finger toward ear until stretch is felt in pinky (5th) finger.
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Treatment Parameters: Hold for 5 seconds and perform 12 repetitions.
7. Core.
This area is of vital importance for the whole body including the wrist and hand. For instance, weak postural stability and deep core stability muscles in the abdominals and gluteals can cause you to overcompensate with the arms. See the lower back section for exercises for this area.
Chapter 7. Golf-Balance Rx
Balance is very important in the golf swing and around the golf course with side hill, uphill, and downhill lies. Since most of us do not test and practice our balance, we tend to lose it as we age. The most common method for testing balance is to balance on one leg for 30 seconds. The quality of your balance is influenced by 3 systems: your sight, your inner ear, and your muscle receptors. As we pass our 50th birthday, we begin to depend more and more on our vision to maintain our balance. You can test this in yourself by first balancing on one leg for 30 seconds, and then repeating the test with your eyes closed.
Also, with your eyes closed you can really feel your muscle receptors around your ankle working overtime to maintain your balance.
The single leg balance test is a great test to determine your risk of falling, however, we rarely need balance to stand still in golf. We need dynamic balance, that is, balance
79 with movement. If you find yourself losing your balance during your swing, than Balance
Rx is for you. The program is designed to begin easy and progress in difficulty as you improve. I suggest performing all of the balance exercises at the most basic level and progressing to the more difficult ones as you feel comfortable. Remember, safety is very important. Make sure that you have something to grab onto for balance if you begin to fall.
1. Single leg stance Difficulty Level - Easy
Setup: Begin by standing in a doorway or at your kitchen sink so that you have something to hold onto in case you lose your balance.
Golf Action: Balance on one leg as shown in the picture above.
Exercise Parameters: Balance for 30-60 seconds.
Keys to Success: Try to balance without holding onto anything with your hands. However, always be aware of safety. Keep your hands close to something that you can grab in case you lose your balance. Once you have mastered this balancing exercise, progress to the more difficult one.
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1.2. Balance Progression Difficulty level – moderate
Modification: Perform the above exercise except, instead of standing on a flat surface, stand on a side hill, downhill, and uphill surface.
1.3. Balance Progression Difficulty level – Difficult
Modification: Perform the above exercise with your eyes closed. Be very cognizant of safety with this exercise. Make sure that your hands are close to an object that you can grab if you begin to fall.
2. Feet together with Exercise Band Cross Pulls Difficulty – Easy/moderate
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Setup: Anchor your exercise band to a door at chest height. Stand sideways to the door and grasp the exercise band with both hands. Stand with your feet as close together as you can safely.
Golf Action: Keeping your arms straight, pull the exercise band across your body in a wide arc.
Exercise Parameters: Perform 12 repetitions facing both directions.
2.2. Balance Progression Difficulty – Moderate
Modification: Face sideways to the door and instead of having your feet together, take a step back with one foot. Perform the same exercise as above.
2.3 Balance Progression Difficulty – Difficult
82 Modification: Stand sideways to the door and instead of having both feet on the ground, stand on one leg. Perform the exercise with your left foot down, then your right. Repeat with both legs facing the opposite direction with your body.
3. Single leg balance with opposite leg reaches Difficulty – Moderate/difficult.
Setup: Stand on one leg.
Golf Action: With your opposite foot, reach as far forward as you are able without touching your foot to the ground or losing your balance. Next, reach as far as you are able to the side. Finally, reach with your leg backwards.
Exercise Parameters: Reach with your leg towards each direction 6 times. Repeat with the opposite leg.
Keys to Success: Don’t reach very far to begin with. Reach further with your leg as you are able to. Again, please be aware of safety.
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