I'm sure the masters of golf became masters following a path of using golf-specific training, the right mobility and weight training, right cardio, right eating and right mind-training. This is the story of one of my patients who is definitely not a master golfer, but he loves to play every week!
Case Study: Treating a Weekly Golfer With Low Back Pain
Stephen says he tries to play a round of golf every Saturday morning. He describes occasional low back pain that causes him to take weeks at a time off from playing. He is 62 years old and works as a coin dealer. He sits a lot! He especially has poor flexibility and tightness in his thoracic spine, hip flexors and hamstrings.
A year ago, he came to me looking for a solution to avoid these painful episodes. After performing my examination including postural evaluation, range of motion, multiple assessments and the Functional Movement Screen (FMS), I sat him down and we had a "Dr. Phil" moment. I explained that he would need to perform therapeutic exercise on a daily basis if he ever hoped to make a change.
I said, "Stephen, the first step is to improve your mobility. I'll work on your soft tissues with the deep muscle stimulator, my hands, and some special tools to decrease your stiffness and inappropriate muscle tone. I'll teach you how to use the foam roll and stretch strap to increase and maintain your range of motion in your ankles, hips, and thoracic spine."
I also explained that mobility is important, particularly in golf, because it dictates the range of motion that he could attain during the swing. The big difference between a pro golfer and a Saturday-morning golfer is that the pro can create greater rotational range and velocities between body segments. I talked to him about core strength and how the core transfers momentum from the lower extremities to the upper extremities.
Session one included a lesson on how to foam roll his calfs, hips and thoracic spine. On session two, I taught Stephen dynamic mobility for his hips and thoracic spine region. I continued with soft-tissue and joint-mobility work. I demonstrated the increase in his range of motion, but also showed him that we needed to work toward achieving symmetrical right- and left-sided movements.
Eight Weeks, 10 Exercises
Stephen did not belong to a gym, but committed to work out at home every day for about 20-45 minutes. I told him to buy elastic tubing with handles, a stability ball, a pair of 5-pound free weights and a 20-pound kettlebell. Ahead of his third session, I constructed a body-weight, band, ball, and free-weight workout. I wrote an eight-week training plan that Stephen would do six days a week, resting at least a day a week.
In another "Dr. Phil" moment, I said, "Do the exercises in the sequence and order that I teach you. Always start with the foam roll and only work the tender or tight areas. Don't waste time doing areas that feel OK. Then perform four or five of the dynamic mobility exercises I taught you." Putting together this therapeutic exercise sequence did take some science and art, but it was all based on the assessments, tests and exams from the first office visit, and then retesting him at the end and beginning of each session, in a "test, teach a repattern exercise, retest" fashion.
These were my instructions for Stephen's program: "Start doing each exercise for 30 seconds. Build up to doing 60 seconds of work or the designated reps for each exercise. Rest only as long as you feel you need to between sets, but no longer than 30 seconds." Here is the overall week-by-week exercise plan (recommended minutes per day):
- Week 1: 20 minutes
- Week 2: 25 minutes
- Week 3: 30 minutes
- Week 4: 35 minutes
- Weeks 5-8: 40 minutes
I told him to begin each exercise session with 5 minutes using the foam roll to the gastrocsoleus, hamstrings, adductors, TFL/glutes, latissimus dorsi, and thoracic spine.
On the next office visit I taught him how to perform the following:
1. Thoracic rotation (mobility). Instructions: Kneel down on all fours, place your right hand behind your head, and point your right elbow out to the side. Brace your core and rotate your right shoulder toward your left elbow/arm. Follow your elbow with your eyes as you reverse the movement until your right elbow points toward the ceiling. That's one repetition. Do 20 reps right and left.
2. Hamstring stretch with core engagement. Instructions: Place the middle of an elastic band (with handles) on a high place like the top of a doorway. Lay on your back with legs straight, grabbing the handles (one handle in each hand). Pull the handles to the sides of your hips to engage the core. Then lift the right leg up to stretch the hamstring. Lower the leg and raise the arms behind the head. Lower the handles to the hips and engage the core. Raise the left leg to stretch the hamstrings. Repeat this 10 times, right and left sides.
Stephen planned on coming in once or twice a week depending on our schedules. On the next session, I taught him how to perform more exercises:
3. Rolling patterns. Instructions: Start out supine with the legs straight and the arms overhead on the floor. Put the left hand to the side of the left head, flex the right knee to the chest, touch the left elbow to the right knee and roll using the core to the right. Roll back to center. Repeat on the other side. Perform 10 reps per side.
4. Quadruped-position (on all fours) resisted diagonals. Instructions: This is an opposite-arm / leg raise using the elastic band (with handles), with the handle of the tube/band around the foot and the other end held in the opposite hand. Perform 10-15 reps per side.
After three weeks of gaining some mobility and starting to control the local core muscles that control segmental translation, it was time to add some more exercises:
5. T push-up. Instructions: Perform a basic push-up, but as you push your body back up, rotate the right side of your body upward and raise your right arm quickly as if you're trying to touch the ceiling. You should be facing sideways with both arms straight, so that they form a "T." Return to the starting position and repeat, this time lifting the opposite arm and turning the other way. As soon as he could, to make it harder, I had him hold a 5-pound dumbbell in each hand as he did the exercise.
Next, I also wanted to reinforce opening the hip flexors and gain some quad and glute strength. I added these exercises:
6. Bulgarian split squat. Instructions: Grab the pair of dumbbells and stand with your back 2-3 feet from a chair. Place your left foot behind you on the bench so that only your instep rests on it. Hold the dumbbells at arm's length at your sides. Keeping your torso upright, lower your body until your front knee is bent 90 degrees. Pause, then push yourself back to the start as quickly as you can. Perform 10-15 reps on the right-leg side, then switch legs.
Shoulder and active straight-leg raise mobility were improving nicely with the exercises he was doing. I continued working manually on the tight joints and tissues with the deep muscle stimulator, and then added:
7. Stability ball plank. Instructions: Place your elbows on the stability ball and your feet on the floor. I had him do static holds building up to a minute. Then I loaded him, challenging him by putting his feet on a chair so that his body was stretched out like it was during a push-up. I said, "Each workout session, try to extend the time you hold the plank by 10 to 15 seconds." It should form a straight line from shoulders to ankles. I taught him to contract and brace his abdominals as hard as he could. He built this position up to 60 seconds, rested 30 seconds, and repeated it one more time.
Moving along in the program, it was time to teach him some:
8. Twisting abs. I know this is a controversial move. I took my chances with Stephen. Instructions: Lie face-up on the floor with both hands holding a kettlebell next to your chest. Keep your knees bent and feet flat on the floor. Curl and lift up so that your torso is almost perpendicular to the floor. Holding the kettlebell in both hands, turn across your body to your left side. Slowly twist your body to your left. Barely touch the bell to the floor. Twist the bell to your right side. Continue the exercise, alternating from side to side.
Weeks were going by and Stephen was able to play golf every Saturday. I would see him on Mondays and usually one other day later in the week. I would reassess his asymmetrical movement or portions of the Functional Movement Screen that needed improvement. I also continued to check the soft tissues and joints, and apply adjustments and fascial therapy as needed.
It was time to add rotational core and power training exercises. Golf involves bending, lifting and twisting. It also requires substantial core strength to stabilize during the swing. Rotational core and power training exercises work clients to move the torso – flexing and extending as it rotates. These are extremely functional golf movements.
We were getting toward the end of the list of exercises I had put together for Stephen. I taught him:
9. Band rotation. Instructions: Stand with your feet slightly wider than shoulder width. Attach the band around a post and face the post. Holding the band handles out in front of your body at rib-cage level (with slight tension), rotate as far as possible to your left until you feel the muscles on your back right side begin to stretch. Drive back in the other direction, keeping your arms extended. Keep rotating until you feel the band wrap around the back of your shoulder. Try to keep your feet stationary and drive the band through the concentric phase (moving the load away from the center) as fast as possible while returning (eccentric) in a controlled manner. The exercise should resemble taking a home-run baseball swing.
The last exercise I wanted to teach Stephen was: 10. Corkscrew. Instructions: Stand with feet shoulder-width apart holding the kettlebell with both hands. Squat down and twist to your right, attempting to touch the weight to the floor behind your right heel. Your left heel should come off the floor as you lower the weight to the floor. Then, as fast as you can, drive the weight back upward and across, finishing with the weight above and behind your left shoulder. Perform all of your reps on one side and then start on the other.
My eight-week lesson plan actually turned into 11 weeks because on a few sessions, Stephen said, "I'm not ready for any new exercises today." He wanted to stay with some of the core moves longer. It all worked out and he and I noticed a little hypertrophy, increased flexibility and strength. I had a third "Dr. Phil" moment with Stephen and explained that he had to continue to improve his sport-specific skills and coordination, and that a golf pro was a good person to consult in this regard.
I am very clear that it is my job to help clients see the "bars" of their own prison and help them "plan an escape." Escaping injuries requires treatment that is both art and science. Those of us into rehab exercise therapy do things because it seems to work. I like the art of it – having the creativity and openness (within professional boundaries) to improve the efficacy of treatment (flexibility, strength, speed, quality of movement, etc.). Knowing which rehab exercises to prescribe helps just that bit more than would otherwise be expected.
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