A Golfer’s Worst Nightmare Rehabilitated Through Massage

For many golfers, the only meaningful way to spend a sunny day is out on the links. With 18 holes to look forward to — the sun’s rays caressing the greens, blue skies inviting deep breathes, and the warm leather grip of a favored club in hand — nothing much can break their joy of being alive.

Until, that is, pain strikes. Pain in the physical sense such as a muscle tear or unstable joint, or the pain they feel from a continually declining game performance. For a die-hard golfer, the two pains are equally worrisome. And, left unresolved, grow to become their worst nightmare: the end of their golfing and no more need for sunny days.

Massage therapists are all well aware that, as the human body ages: muscles atrophy, tissues lose elasticity and overall flexibility declines. What many therapists have yet to fully understand, however, is that static stretching of muscles is rarely enough to correct these affects (Siff and Verkhosansky 1993, Siff 1994, and 1998). And even dynamic stretching is an incomplete course of treatment for many of our clients — especially those who golf.

Kinematic Sequencing and Therapeutic Improvements

To effectively assess and treat the unique needs of a golf client requires that the therapist first acquire an advanced knowledge of body dynamics, namely, the kinematic sequencing of the golfer’s body.

Kinematic sequencing refers to the specific order that the body engages its muscles, bones, joints and balance to perform a movement. In our golfing clients, the movement is striking the ball.

For an efficient golf swing to take place, the process of kinematic sequencing looks like this:

• First, the pelvis is engaged and rotates towards the ball.
• Second, the trunk engages and follows the pelvis.
• Third, the arms engage and follow the trunk.
• Fourth, the hands and club follow the arms until the ball is struck.

Once the ball is struck, the body again engages in a kinematic sequence, this time of deceleration, with the pelvis engaging first, followed by the trunk, followed by the arms, followed by the hands and club. That is good sequencing.

As massage therapists, the better we understand kinematic sequencing — especially in our rotational athletes who play golf, tennis, baseball, bowling and soccer — the the better we become at assessing our clients’ pains, restrictions, limitations and frustrations.

And the first step to better assessing our clients is to perform better evaluations. Specifically, how they present when they take a static posture and when they take a dynamic posture as they describe their pains, restrictions and issues.

Static posture is, of course, the position of the body at rest, sitting, standing or lying down. This is typically what we see most often as massage therapists. Our clients sitting or standing before us or perhaps already laying on the table as they describe their pains and wait for us to treat them.

Dynamic posture, on the other hand, has the patient: move, twist, lift, pull, push and balance in order to reveal the likely causes of the client’s pain or imbalance. The difference in evaluating your client’s condition using dynamic posture as well as a static posture is often the critical and missing step in properly assessing and treating our patients (Doctor Vladimir Janda “Upper and Lower Cross Syndrome” 1979, cited in Lewitt 1999).

To only evaluate your client in a static posture would be missing the holistic nature of human dynamic motion and posture. Sure, you can look at a left hip internal rotation when your client is on the table and find a deficiency of say 15-20 degrees, but that won’t give you an accurate picture of what’s really affecting the golf swing until you ask your client to stand up and perform the very movement that causes the trouble. So to replicate the golf swing, you must ask your client to do an internal rotation so as to move the trunk over the hip.

Frankenstein on the Golf Course

Here’s an example from my own clinic. I recently had the opportunity to work with a golfer who had bilateral hip replacements, a right knee replacement, and a left shoulder injury that was never repaired. I hate to say it, but he walked like Frankenstein and, as you can predict, his traumas lead to a continuing decline in his game performance.

When golfers ready themselves to strike the ball they bend their knees into a semi-squat formation. So to properly assess my client’s condition, I asked him to squat, slowly, all the way into a chair. And as he did so, I observed his ankles, knees, hips, trunk and motor control. I then asked him to stand on one leg. His ability to maintain a one-legged posture lasted less than three seconds. I also noted that he could not even begin to touch his toes; and he had limited trunk control, pelvic and spinal rotation. He had a forward head posture, kyphosis, and evaluation of his left shoulder joint presented the arm well in front of his ear instead of the proper placement which is beside or behind the ear. As you might infer, he clearly needed better flexibility. But, because of his hip prosthetics, it would be inadvisable to stretch his hips into internal rotation.

For this client, I began by making a basic golf movement better. Namely, the squat. Simply by teaching him to use his hips better, it allowed him to stay in a golf posture longer which helped with his swing path, tempo and striking distance — and his enjoyment of the game. We always combined our sessions with manual therapy, focusing around the hip rotators, to help him improve his hip hinge.

If you are ever presented with a client suffering with similar impairments, begin by writing down your assessment of how each muscle is affecting the joints in the lower extremities. Look at the flexibility of the feet as they relate to overall stability during weight shifts. Create more ankle mobility by addressing the dorsiflexors and removing myofascial restrictions. Check the client for the ability to do inversion and eversion of the ankles. Attempt to lengthen the quads, hamstrings, adductors, IT band, gluteals and psoas. Your goal is to increase the length of the flexor chain and increase strength to the extensor chain.

Once you’ve completed all of the above, recheck the client’s movement by asking your client to perform another squat or the movement pattern that is causing the concern. If your client has yet to improve, it may indicate that just stretching the lower extremity is not enough. Adding mobility without adding stability may not change the movement pattern. You may need to become a teacher of the squat. Put a chair behind the client, have them do an isometric press into their hands to activate the core, and teach them to hip-hinge back into the chair. Then repeat your manual therapy and re-check your client’s range-of-motion. Continue to do this as many times as necessary throughout the session to reveal how much your client’s motor control is improving. You will often see minor improvements during the first session and noticeably bigger improvements during subsequent appointments.

This is the protocol I implemented with my own client and he improved dramatically. In just three months, I had him transform his gate from that of a B-movie monster to that of a young man walking with a kick in his step. He also lowered his golf handicap, feels younger, stands taller and more importantly . . . he is now free of his worst fear — that of believing that he’d never again enjoy playing 18 rounds of the great game of golf.

References

1. Supertraining: Yuri Verkhoshansky and Mel Siff.
2. Manipulative Therapy in the Rehabilitation of the Locomotor System: Karel Lewit, Third Edition 1999.
3. Superstretch : Mel Siff 1994.
4. Facts and Fallacies of Fitness : Mel Siff 1998.