Case study

A physiotherapy perspective on improving swing technique

in a professional golfer: a case study

Lynn Booth*

English Ladies Golf Association, Edgbaston Golf Club, Church Road, Birmingham B15 3TB, UK

Received 15 July 2004; revised 24 January 2005; accepted 30 January 2005

Abstract

Providing information regarding the use of physiotherapy or related musculoskeletal conditioning to improve a sporting technique requires

experience of the sport in question, and knowledge of relevant research evidence and functional anatomy and their application to the sport.

Physiotherapists and other rehabilitation providers working with athletes must also ensure that they are working to the specific requirements

of the athlete and coach.

This case study outlines the effect of physiotherapy intervention over a 2-year period on the swing of a professional golfer. The essential

components required to produce a good result when treating sports injuries are highlighted. Such components include a detailed discussion

between the golfer, coach, and physiotherapist, the use of digital performance analysis, and the application of relevant musculoskeletal

profiling. Taking this approach provides a platform on which to devise an appropriate exercise intervention.

q 2005 Elsevier Ltd. All rights reserved.

Keywords: Golf; Musculoskeletal profiling; Sports injuries; Sports skills

1. Introduction

After 7 years experience of working with regional,

national, junior, and adult elite amateur golfers, I was

approached by a Professional Golf Association (PGA)

coach to provide an opinion on whether any aspect of

physiotherapy or related musculoskeletal conditioning

could improve the swing technique of a 30-year-old female

professional golfer.

The golfer, a naturally right-handed player who played

with right-handed clubs, played on the Women’s European

Tour and frequently received physiotherapy treatment and

massage, mainly for the upper limbs and cervico-thoracic

spine, from physiotherapists working on the Tour and in her

local region. Due to the constant travelling to competitions,

however, the golfer was seldom at home long enough for

underlying causes of injury to be identified and adequately

addressed.

1466-853X/$ - see front matter q 2005 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ptsp.2005.01.003

* Tel.: C44 7770 236 226.

E-mail address: physiolynn@aol.com.

The golfer and her coach had decided that the priority

during the winter (non-competitive) training season would

be to modify her swing, in particular to develop a better

swing plane. Observing the golfer work with the coach,

followed by a musculoskeletal profiling session, highlighted

several areas that might benefit from physiotherapy

intervention. In general, these were a kyphotic thoracic

posture, reduced thoracic mobility, reduced stability and

control of scapulothoracic and lumbopelvic regions, and

weak lateral rotator cuff and abdominal oblique muscles.

These areas of concern are detailed more specifically under

the assessment section of this paper. In order to fully

understand the relationship between the golf swing and

physiotherapeutic methods a brief review of relevant

literature follows.

2. Review of literature

Reviewing relevant papers on common golf injuries (e.g.

Batt, 1992, 1993; Brendecke, 1990; Burden, Grimshaw, &

Wallace, 1998; Burdorf, van der Steenhovenm, & Tromp-

Klaren, 1996; McCarroll, Rettig, & Shelbourne, 1990;

Metz, 1999; Nissinen et al., 2000; Seaman, 1998; Theriault

Physical Therapy in Sport 6 (2005) 97–102

www.elsevier.com/locate/yptsp

L. Booth / Physical Therapy in Sport 6 (2005) 97–10298

& Lachance, 1998) helped to define the areas that should be

considered during the physiotherapy musculoskeletal

assessment.

Batt (1993) and Pink, Jobe, and Perry (1990) described

the mechanics of the golf swing as requiring rapid

glenohumeral movement through a large range of move-

ment, necessitating an intact and functioning rotator cuff

firing in synchrony to provide a coordinated movement to

protect the glenohumeral complex. At the top of the

backswing the left arm of a right-handed golfer is in

maximal horizontal adduction and internal rotation.

Although shoulder elevation during the golf swing is not

usually greater than 908 in either shoulder until the end of

the swing, anterior joint line pain may be indicative of

impingement of the humeral head against the anterior

labrum (Jobe & Pink, 1996). Muscles responsible for

scapulae stabilisation have an important role in preventing

impingement (Regan, 1996). Batt (1992) reported that

shoulder injuries only accounted for 2% of the total injuries

of 193 amateur golfers. However, the golfers in Batt’s

(1992) report represented only a 42% response rate from one

golf club with an average age of 38.5 years and an average

handicap of 10.2. Studies on professional golfers have found

that the back, wrist, and shoulder were the most common

injury sites (McCarroll & Gioe, 1982), the injuries were

usually overuse in nature and right-handed golfers had more

frequent problems in the left upper limb (Theriault &

Lachance, 1998). Jobe and Pink (1996) reported only 98

new shoulder injuries (7.7%) in a 5-year period although

this was on the Seniors PGA Tour, where golfers were 50

years and older.

In a series of studies by one research group (Jobe,

Moynes, & Antonelli, 1986; Jobe, Perry, & Pink, 1989; Pink

et al., 1990), it was identified that the muscle work required

around the shoulder complex during the golf swing in

professional golfers was no different between men and

women in relation to the firing patterns of normal shoulder

musculature. A search of the literature has not identified any

studies detailing the muscular firing pattern in the shoulders

of injured golfers.

From extensive experience in working with elite

amateur golfers it is evident that, although acute

traumatic shoulder injuries do not commonly occur,

several elite (junior and adult) amateur golfers did

complain of chronic shoulder injuries. Jobe et al. (1986)

suggested that there might be more erratic firing of the

rotator cuff muscles in amateur golfers compared to

professional golfers. This does not reflect my own

experience that both amateur and professional golfers

complain of shoulder problems. It could be that Jobe

et al.’s (1986) definition of ‘amateur golfers’ actually

refers to recreational golfers rather than elite amateurs. As

refining the swing plane of the golf swing is a constant

coaching point for both amateur and professional golfers,

the importance of shoulder girdle and glenohumeral

control could not be overlooked.

Pink et al. (1990) suggested that as a golfer uses both sides

of the body in synchrony, right-handed golfers should

strengthen the left rotator cuff muscles to at least the levels

of the right shoulder. Exercise programmes for golfers should

include bilateral strengthening of the rotator cuff muscles to

provide a coordinated and protected movement during the

rapid, but not necessarily strenuous, arm activity. Biannual

musculoskeletal profiling of golfers by chartered phy-

siotherapists working for the English Ladies Golf Associ-

ation and the English Golf Union has shown that, in common

with other sports, the lateral rotator cuff muscles (infra-

spinatus and teres minor) tend to be weaker than the medial

rotator cuff (subscapularis) (Codine, Bernard, Pocholle,

Benaim, & Brun, 1997; Hall, Milligan, & Stewart, 1995).

An effective and efficient golf swing, that reduces the

propensity for injury, requires the spine–hip angle to remain

constant, which in turn requires good trunk and hip rotation

(Booth & Forrest, 1999). Golf coaches use the term ‘spine–

hip angle’ to refer to a combination of spine/pelvis and

pelvis/thigh angles. Booth and Forrest (1999) suggested that

in order to enhance performance and reduce the likelihood

of low back pain, golfers must try to attain 908 trunk rotation

in both directions in sitting.

In common with other sports, golf coaches differ

amongst themselves on the technical aspects of the golf

swing, and it is important that physiotherapists and other

rehabilitation providers working with golfers and coaches

ensure that they are working to the coach and golfer’s

specific requirements.

The author’s experience of musculoskeletal profiling of

elite amateur golfers had highlighted several common

themes, which were considered when assessing this

particular golfer. These themes included:

†

At the address position (the stationary position before the

golfer starts to move the club), the right hand is lower

than the left on the shaft of the club resulting in the right

shoulder being lower than the left. This habitual posture

results in some golfers demonstrating a scoliosis concave

to the right in standing, and many golfers show tightness

of the left upper trapezius and left levator scapulae with

associated lengthening of the right upper trapezius.

†

Despite being able to demonstrate good thoracic rotation

some golfers still tend to lose the spine–hip angle or to turn

the whole body rather than just the trunk. The study by

Bechler, Jobe, Pink, Pery, and Ruwe (1995) highlighted the

muscle work in the hip and knee during the golf swing,

showing a sequential firing of muscles that generate power

from the lower limbs through the trunk to the upper limbs.

†

Whiteley (1999) suggested that higher handicap golfers,

in an effort to increase the ball-flight distance, try to

generate extra power from the muscles of the shoulders

and arms rather than the trunk. In the author’s experience

the same applies to elite amateur golfers, thus placing

additional strain on the stabilisers of the scapulae and

glenohumeral joints. Mottram (1997) and Regan (1996)

L. Booth / Physical Therapy in Sport 6 (2005) 97–102 99

highlighted the importance of static and dynamic

scapulae setting and discussed basic scapular stabilising

exercises that should allow golfers to control the golf

club during the swing.

†

A majority of golfers have poor endurance and strength in

the muscles of the lateral rotator cuff compared to the

medial rotatorcuffmuscle, particularly in the left shoulder.

Voight, Hardin, Blackburn, Tippett, and Canner (1996)

suggested that treatment protocols should emphasise

muscle endurance as shoulder proprioception (the ability

to reproduce a pre-established position) is diminished in

the presence of shoulder muscle fatigue. Scoville, Arciero,

Tayloy, and Stoneman (1997) suggested that the ratio of

eccentric lateral rotator cuff muscles to concentric medial

rotatorcuffmuscles inasymptomatic males was 1.08:1 and

1.05:1 in dominant and non-dominant shoulders, respect-

ively. Their study, however, had several shortcomings; the

subjects had their upper body fixed by restraining straps,

the shoulders were only tested between 908 of lateral

rotation and 208 of medial rotation (not end-range for

medial rotation of the shoulder), and the isokinetic speed

was set at 908/s. Increasing the speed and extending the

lever by using a golf club would be expected to increase the

ratio. Ellenbecker (1996) demonstrated that isokinetic

testing of the medial and lateral rotators of the shoulder

showed significant differences in subjects with normal

grade strength measured using manual muscle testing.

However, the study used isokinetic speeds of 210 and

3008/s (far too slow to mimic a golf swing) and isometric

manual muscle testing.

†

In the absence of an objective test of rotator cuff strength

that can be used ‘on the range’ rather than in a laboratory,

the author is still assessing muscle strength subjectively—

using testing procedures suggested by Kelly, Kadrmas,

and Speer (1996), who used EMG (surface and indwel-

ling) on the non-dominant shoulders of 11 normal subjects

to establish the optimal manual muscle test for the rotator

cuff muscles, although there is no mention of teres minor.

†

Although there is no research using randomised con-

trolled trials to support the claim, many people

associated with golf (players, coaches, support staff)

suggest that improved lumbar/pelvic stability results in

improvement in ball-flight distance.

†

To reduce the strain on the upper limbs (Whiteley, 1999),

and in line with the findings of Watkins, Uppal, Perry,

Pink, and Dinsay (1996), golfers require trunk rotator

strength in outer range.

3. Initial contact

3.1. Assessment

The golfer’s local physiotherapist had suggested that the

golfer’s posture was too kyphotic, that she had poor weight

transference, was over-rotating her upper thoracic spine to

achieve distance during a full swing, and hyperextending

her upper cervical spine to get her eyes over the ball when

putting. The golfer’s posture and abdominal control had

subsequently benefited from Pilates intervention.

It was important to review the golfer’s swing with the

PGA coach using high-resolution digital cameras and

electronic software. This allowed the swing action to be

evaluated in both sagittal and coronal planes and at normal

and slow speeds. Subsequent detailed discussion of the

swing dynamics and the physical demands being placed on

the golfer allowed interpretation of the coach and player

requirements, and provided a platform on which to devise

relevant musculoskeletal assessment and exercise

intervention.

Digital analysis of the swing showed that the golfer did

not over-rotate the thoracic spine during the swing but

actually over-protracted the left scapula. This fault had

probably developed to compensate for a lack of right trunk

rotation whilst still attaining the correct position of the club

head at the top of the backswing, and could explain the

recurring pain in the left scapula and upper arm, which had

caused the golfer to seek treatment during the season.

Using information from the relevant literature and

previous experience, the musculoskeletal assessment was

carried out. Salient points from the assessment of the golfer

included:

†

Established kyphotic thoracic posture

†

Sitting trunk rotation; rightZ758, leftZ708

†

Reduced scapulae stability and control; leftOright

†

Weak concentric lateral rotator cuff muscles compared to

concentric medial rotator cuff; left and right

†

Poor lumbar/pelvic stability

†

Very weak outer range abdominal oblique muscles; left

and right

†

Pain and stiffness on palpation of T5-7 centrally.

3.2. Treatment

A regime of exercises was developed to address the

issues found on assessment. In particular, emphasis was

placed on the importance of improving trunk rotation

(Booth & Forrest, 1999), lumbar/pelvic control, and

scapulae stability and control (Moseley, Jobe, Pink, Perry,

& Tibone, 1992). Moseley et al. (1992) used EMG analysis

on nine healthy subjects with no shoulder pathology to

evaluate exercises in their ability to strengthen the scapular

muscles. For this golfer, the exercises suggested by Moseley

et al. (1992) were modified to avoid glenohumeral flexion

above 908 to reduce the risk of impingement of the humeral

head against the anterior labrum. The range of shoulder

flexion was slowly increased as the concentric lateral rotator

cuff strength improved. A resistance cord was also used to

strengthen the lateral rotator cuff muscles, in order to

develop the posterior ‘biased’ shoulder described by Davies

L. Booth / Physical Therapy in Sport 6 (2005) 97–102100

and Dickoff-Hoffman (1993). Although golf is an open

kinetic chain exercise for the shoulder joint, both open and

closed kinetic chain exercises were used to help develop

dynamic stabilisation of the scapulae and glenohumeral

joints based on the suggestions by Wilk, Arrigo, and

Andrews (1996). As well, the progression of exercises

developed by Sahrmann (2002) was used to introduce

transversus abdominis into the golf swing to enhance the

golfer’s spinal stability and control.

Within six weeks of starting the exercise regime, the

golfer was able to incorporate some muscle control at

address position, and was aware of the need to continue to

work on the programme in order to improve muscular

control during the swing.

4. Two years later

After a further two seasons on the European Tour, the

player requested another assessment prior to commencing

her winter training programme. She was still working on

swing modifications and had experienced chronic injury

problems with her right shoulder during the previous season.

According to the player, an ultrasound scan had shown

inflammation (but no tear) of the biceps tendon and an

orthopaedic surgeon had injected the shoulder (specific site

not known) three months previously with initial relief.

After resting for three weeks she had played on the Tour

although did not recommence any upper body conditioning

work. The golfer had then been provided with a series of

shoulder exercises, including ‘core exercises and resistance

cord work’. After performing the exercises for one week the

golfer started to complain of pain in the right biceps tendon

and muscle, but nevertheless started a weights programme

including chest press, upright rows, shoulder abduction, and

lat pull downs. Local treatment (ultrasound, interferential)

had failed to resolve the right shoulder and upper arm pain

and four days prior to the assessment the golfer had stopped

playing after 10 holes due to pain around the insertion of

deltoid. Importantly, the golfer admitted that once the

competitive season had started, she had neglected the

exercise regime developed 2 years previously.

4.1. Assessment

A thorough assessment as again carried out. Salient

points from this assessment included:

†

Kyphotic upper thoracic spine with poking chin—in her

general and golf posture

†

Good lumbar/pelvic control

†

Tightness in left upper trapezius muscle

†

Lengthening of right upper trapezius muscle

†

Sitting trunk rotation; rightZleftZ858

†

No abnormalities were detected in the cervical spine

†

No weakness of upper arm muscles

†

Reduced scapulae stability and control; rightOleft

†

Medial rotation of the right shoulderZ308. This was

measured from the neutral position for rotation (i.e. lying

supine, with 908 glenohumeral abduction, elbow flexed

to 908, and the forearm vertical) (Herrington, 1998).

Medial rotation of left shoulderZ508

†

Very weak posterior rotator cuff muscles in eccentric

outer range; rightOleft. This would be required to

control the glenohumeral joint as the range of shoulder

medial rotation improved.

It became apparent that the golfer was ‘trying too hard’ to

correct her scapulae posture and was using the larger phasic

muscles of the upper back rather than the postural control

muscles of the scapulae—the substitution strategies dis-

cussed by Mottram (1997). However, Mottram (1997) also

suggested that with increasing loads (long limb lever) the

scapulae stabilisers must work above 30% of their

maximum voluntary contraction, although no evidence is

provided. The resistance cord work for the right shoulder

had been forcing the shoulder beyond its physiological

range of medial rotation. This could have an effect on

anteroposterior translation of the humeral head (Branch,

Avilla, London, & Hutton, 1999; Davies & Dickoff-

Hoffman, 1993; Kamkar, Irrgang, & Whitney, 1993),

although Branch et al.’s (1999) study, which demonstrated

the relationship between the length of the posterior capsule

and humeral translation during medial rotation, was

undertaken on cadavers (i.e. without muscular control).

4.2. Treatment

Using video analysis, and together with the coach, the

necessity to improve scapulae stability, general and golfing

posture, the range of right shoulder medial rotation, and the

eccentric strength of the posterior rotator cuff muscles was

stressed to the golfer. Slow motion video also highlighted

over-contraction of the right upper fibres of trapezius at the

top of the backswing, which changed the direction of the

swing plane—for this reason it was decided not to include

strengthening exercises for the right upper trapezius in the

exercise programme.

The lack of consistent improvement over the previous six

months and the golfer’s realisation that her game was being

compromised meant that she was more amenable to

committing to a relevant exercise programme. The golfer’s

rehabilitation was modified. The recent weights and

resistance cord work were stopped and the following

exercises were commenced:

†

Mobility exercises for

B Posterior capsule of the right shoulder (Branch et al.,

1999)

B Medial rotation of the right shoulder in 908 abduction

†

Active stretching of left upper trapezius and levator

scapulae

L. Booth / Physical Therapy in Sport 6 (2005) 97–102 101

†

Scapulae control and setting, avoiding any secondary

muscle contraction, initially in prone lying progressing to

standing

†

Eccentric posterior rotator cuff strengthening, using

resistance cord in painfree range in supine lying with

shoulder abducted to 908.

The glenohumeral medial rotation stretching technique

suggested by Johansen, Callis, Potts, and Shall (1995) for

baseball pitchers was not used, as the method requires an

outside force to apply pressure to the scapulae in prone

lying. In order to develop compliance it was decided that all

the golfer’s exercises should be self-managed.

A lot of time was spent on the range with the golfer and

her coach practising improved posture at the address

position and during the swing. As one would expect, the

golfer was able to maintain a good posture at the address

position quite quickly, but was unable to maintain this as

soon as she moved the golf club. The golfer found it easier

to improve scapulae control when she combined this with

her ability to maintain lumbar/pelvic control using a sub-

maximal contraction of transversus abdominis.

One month later, the golfer had committed well to the

exercise programme and reported only slight ‘muscular

aching’ in the right upper arm. Medial rotation of the right

shoulder in 908 abduction had improved to 458. The exercise

regime was modified again to improve the eccentric strength

of the posterior rotator cuff muscles throughout the painfree

range and to commence plyometric (stretch-shortening)

exercises in middle range (Davies & Dickoff-Hoffman,

1993; Wilk et al., 1993).

The golfer, coach, and physiotherapist worked constantly

on improving spinal posture, shoulder girdle stability and

control throughout the swing, as well as the necessary swing

modifications. It may be that the improved muscular control

and endurance influenced the kinaesthetic receptors and

helped the golfer to make subtle adjustments in her golf

swing (Furness & Wellington, 1997; Voight et al., 1996),

although Voight et al.’s study focused on asymptomatic

shoulders and was unable to detect if the subjects could

perceive the threshold of passive movement.

Once glenohumeral and scapulae control was maintained

on the range under practice conditions, where all three

participants (golfer, coach and physiotherapist) could refer

to video analysis when necessary, the physiotherapist

walked nine holes with the golfer and coach observing,

discussing, and where necessary modifying the golfer’s

posture, shoulder girdle stability, and control under more

realistic golfing conditions.

5. Conclusion

The golfer has resumed competition on the European

Tour, has had no reported recurrence of the shoulder

problems, and has performed well during tournaments.

This case-study highlights the essential components

required to produce a good result when treating sports

injuries. Theses components include:

1.

Commitment of the golfer/athlete

2.

Interest and involvement of the coach

3.

Use of performance analysis equipment

4.

Knowledge of functional anatomy and its application to a

particular sport

5.

Ability of support staff to apply their knowledge to

particular facets of the sport and revise their opinions in

light of on-going findings.

Acknowledgements

This case study was written as part of the author’s

submission to the British Olympic Association’s (BOA)

Physiotherapy Register.

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