Exercises(for(Improving(Hip(Rotation( - FLVC27397... · 2015-06-26 · Exercises(for(Improving(Hip(Rotation(USE OF GOLF SPECIFIC FUNCTIONAL ASSESSMENT AND EXERCISES FOR IMPROVING

Exercises for Improving Hip Rotation

USE OF GOLF SPECIFIC FUNCTIONAL ASSESSMENT AND EXERCISES FOR

IMPROVING RIGHT HIP INTERNAL ROTATION LIMITATIONS IN A RIGHT

HANDED GOLFER

A Case Report

Presented to

The Faculty of the College of Health Professions and Social Work

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor of Physical Therapy

By

Raymond N. Agostino

2015


APPROVAL SHEET

This case report is submitted in partial fulfillment of

the requirements for the degree of

Doctor of Physical Therapy

__________________________________

Raymond N. Agostino

Approved: May 2015

___________________________________

Shawn D. Felton, EdD, ATC, LAT

Committee Chair / Advisor

___________________________________

Stephen A. Black, D.Sc, PT, ATC/L, NSCA-CPT

Committee Member

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline.


Acknowledgements

I would like to thank Darin Hovis, ATC, ACE Certified Personal Trainer, Titleist

Performance Institute Certified Level 3 Golf Medical and Fitness Professional, for

supervising the assessments and interventions performed as part of this case report. I

would also like to thank Dr. Shawn D. Felton, EdD, ATC, LAT and Dr. Stephen A.

Black, D.Sc, PT, ATC/L, NSCA-CPT for their continued guidance and support. I would

also like to thank my wife, Noelle Agostino, for her unwavering support and patience

throughout this entire process. This would not have been accomplished had it not been

for her encouragement.

Exercises for Improving Hip Rotation 4

Table of Contents

Abstract 6

Introduction / Background 8

Figure 1: Number of U.S. Golfers, projected to 2020 8

The Golf Swing

Phases of the golf swing 10

Figure 2: Phases of the golf swing 10

Figure 3: Leading towards target with hip rotation 11

Trailing Hip Biomechanics 12

Backswing 12

Downswing 13

Hip rotation benchmarks 13

Trailing Hip Limitations & Dysfunctions 14

Golf -related injuries 14

Analysis & Interventions 15

Intervention programs 15

Client History / Review of Symptoms 17

Clinical Impression 18

Examination 18

Tests and Measures 18

Functional Screening 18

Hip Active ROM 19

Hip MMT 19


Numeric Pain Rating Scale 20

Figure 4: Numeric Pain Rating Scale 20

Table 1: Physical Examination Key Findings 21

Clinical Impression 21

Intervention (Application of Theory to Practice) 22

Outcomes 22

Discussion 23

References 25

Appendices

Appendix A: Titleist Performance Institute (TPI) Screen 27

Appendix B: Specific Exercises 33


Abstract

Background: Greater range of motion for hip internal rotation in the trail (right)

hip of a right-handed golfer is a characteristic shared by golfers who are sub-10 handicap

players (Sell, Tsai, Smoliga, Myers, & Lephart, 2007). Improving right hip internal

rotation can be an effective way of improving the proficiency of an amateur golfer.

Client History: A 42-year-old male consulted his sports medicine specialist because of

decreased bilateral hip range of motion and bilateral hip pain that he determined to be the

cause of his increased golf handicap index. He was referred to outpatient fitness training

where he revealed that his pain symptoms were: prolonged sitting and walking, multiple

golf swings, and playing golf for longer than one hour. During the time of initial

assessment, the client reported that no previous interventions had been provided.

Examination: As part of the initial assessment, a TPI Certified Level 3 Golf Medical

and Fitness Professional administered a Titleist Performance Institute (TPI) functional

screen. This functional screen consisted of sixteen separate assessments to determine the

clients golf fitness level, and was used to decide prescribed exercise interventions.

Additional assessments included objective measurements of bilateral active hip flexion

and internal rotation range of motion, manual muscle testing of bilateral hip flexion,

internal and external rotation, as well as conducting a self reported numeric pain rating

scale survey. Intervention: The intervention plan consisted of twenty-four treatment

sessions over an eight-week period. Each session entailed completing ten dynamic

exercises, all of which were supervised by the assessing TPI professional. These

exercises focused on increasing bilateral hip mobility and strength. Outcomes:

Objective measurements were taken again at the end of the eight weeks, and there were


noted increases in strength and range of motion, as well as a pronounced decrease in pain

levels. Discussion: This case illustrated the potential for specific exercises based on a

functional assessment to improve measurable aspects of golf performance.


Introduction/Background

Golf has become an increasingly popular and distinctive sport for players of all

ages, sex, and athleticism. A 2003 report stated there were over 55-million golfers

worldwide (Lephart, Smoliga, Myers, Sell & Tsai, 2007). In 2011, the National Golf

Foundation reported that golf attracted approximately 25.7 million participants in the

United States alone. This number is expected to reach approximately 30.2 million by the

year 2020 (National Golf Foundation, 2012). Figure 1 identifies the number of golfers in

the United States from the year 1986, projected to the year 2020.

Figure 1. Number of U.S. Golfers, projected to 2020 (National Golf Foundation, 2010).

Along with the increase in number of golf participants, there has also been an

increase in the length of time that individuals are playing golf. Age has been shown to

have a limited effect on high performance and skill, and a golf career can last for more


than 50 years (Cabri, Sousa, Kots & Barreiros, 2009). Several techniques to improve

longevity and performance in golf have been implemented, and three specific techniques

have been described in recent studies. One method that golfers are using to improve

performance is purchasing equipment with the latest technology. According to a report

from the National Golf Foundation, $5.639 billion was spent on golf supplies, including

equipment, in the year 2011. A second method being used is the improvement of swing

mechanics, as taught by PGA professionals or certified golf instructors. This type of

instruction can reduce swing faults and allow for a more reproducible swing. PGA

professionals can also help improve individual aspects of a golfer’s game, such as

driving, chipping, and putting. A third method of golf improvement being utilized is the

enhancement of swing biomechanics. Physical training, as prescribed by movement

professionals, such as physical therapists, athletic trainers, or strength and conditioning

coaches, has been shown to improve the biomechanics needed for the golf swing, thus

improving specific golf performance measurements, such as clubhead speed and ball

speed. Achieving these proper biomechanics requires a combination of balance,

flexibility, and strength to combine the movements of several segments of the body (Sell

et al., 2007).

The Golf Swing

Each golf swing can be described as a variation of one of two swing styles. One

is called the modern golf swing and the other is called the classic golf swing. Each of

these swings requires distinctive biomechanics that have different effects on the range of

motion of various joints of the body (McHardy, Pollard, & Bayley, 2006). Healy et al.

(2011) supported the hypothesis that differences in joint kinematics are evident between


golfers who achieve a greater hitting distance and those who achieve a lesser hitting

distance. This was also supported by Chu, Sell, & Lephart (2010), who described swing

mechanics as the most important for optimal golf driving performance. The classic golf

swing promotes hip rotation and decreases the torque on the lower back. Lifting the front

heel during the backswing, completing a shorter backswing, or a combination of these

two methods, results in increased hip rotation. The modern swing demands a greater

shoulder turn while keeping the hips relatively restricted. The greater shoulder turn and

relative restriction of the hips is a result of maintaining a flat front foot during the swing,

therefore decreasing the motion in the lower extremities throughout the swing (McHardy

et al., 2006).

Phases of the golf swing. Incorporated within each of these swing styles are

three phases of the golf swing that can be examined using functional movement analysis.

The swing phases are the backswing, the downswing, and the follow-through (Figure 2).

Some authors include an acceleration phase and impact phase that occur between the

downswing and follow-through, in order to further breakdown the biomechanical motions

needed to produce an effective golf swing (Chu et al., 2010).

Figure 2. Phases of the golf swing.

(1) backswing (2) downswing (3) follow-through


The goal of the backswing is to position the golfer’s center of mass and clubhead to

produce a great amount of potential energy in preparation for the downswing (Hume,

Keogh, & Reid, 2005). This coiling mechanism of the backswing involves a separation

between the upper torso and pelvis, and the purpose is to store energy that eventually is

released to produce clubhead speed at impact (McHardy et al., 2006). According to

Burden, Grimshaw, and Wallace (1998), the upper body begins to rotate away from the

target before the hips at the start of the backswing. The duration of the backswing in elite

golfers is less than one second, resulting in 60-80% of weight transferring to the right

side, or trailing side, assuming a right handed swing (Hume et al., 2005). The

downswing begins just prior to the completion of the backswing, and is initiated by an

uncoiling mechanism, lasting approximately 0.30 seconds +/- 0.06 seconds. Left pelvic

rotation begins towards the target before the arms complete the backswing (Figure 3), and

the uncoiling mechanism continues throughout the downswing.

Figure 3. Leading towards target with hip rotation.


The kinetic chain reaction of the downswing continues with the uncoiling of the trunk

and shoulders, and ends with the wrists and hands. This transition promotes a whipping

action at the shoulders, which extends distally to the hands, and as a result, the golf club.

Burden et al. (1998) described this phenomenon as the ‘summation of speed principle’,

stating that the maximum speed of hip rotation is followed by a greater maximum speed

of shoulder rotation during the downswing. In 75% of golfers studied, the downswing

began while the shoulders continued rotating away from the target as the hips began

rotating back towards it. Following the downswing phase, the follow through phase

begins after impact with the golf ball. Immediately following impact, eccentric muscle

action is used to decelerate the body and the clubhead (McHardy & Pollard, 2005). As

the follow-through continues, there is a proximal to distal deceleration of the body,

allowing for a controlled completion of movement. The full follow-through swing phase

is a continuation of the follow-through, and begins when the club is horizontal to the

ground.

Trailing Hip Biomechanics

Backswing. The coiling action of the trailing hip during the backswing phase of

the golf swing is the result of the right hip going through flexion, adduction, and internal

rotation, and ending in a flexed, adducted, and internally rotated position, respectively.

The most active muscles in the right hip during the backswing coiling mechanism are the

semimembranosus and the long head of the biceps femoris, with 28% and 27% of

maximal manual testing recruitment, respectively (McHardy & Pollard, 2005). To

produce these motions, internal peak hip torques generated during flexion, adduction, and

internal rotation are 6.56 Nm +/- 1.73, 4.95 Nm +/- 1.88, and 2.7 Nm +/- 1.15,


respectively (Foxworth et al., 2013). The motions of the right hip during the backswing

can be limited by ligamentous structures including: the iliofemoral, pubofemoral,

ischiofemoral, ligamentum teres femoris, and the ligamentum orbicularis (Torry,

Schenker, Martin, Hogoboom, & Philippon, 2006).

Downswing. The transformation from the backswing to the downswing is

initiated in the right hip by extension, abduction, and external rotation. The hip extensors

and abductors of the right hip initiate the powerful left pelvic rotation to start the

downswing. The muscles with the greatest level of activation during this transition are

the upper and lower gluteus maximus, with 100% and 98% of maximal manual testing

recruitment, respectively (McHardy & Pollard, 2005). To produce these motions,

internal peak hip torques of this powerful uncoiling are 10.64 Nm +/- 1.96, 5.69 Nm +/-

1.21, and 2.38 Nm +/- 0.84 for hip extension, abduction, and external rotation,

respectively (Foxworth et al., 2013). All of these factors work simultaneously to

optimize the biomechanics of the hip joint and create proper transitioning from one swing

phase to the next.

Hip rotation benchmarks. Burden et. al. (1998) determined that seven out of

eight golfers rotated their hips between 35 degrees and 48 degrees. The entire study

population also counter-rotated towards the target through a range of 52 degrees +/- 17

degrees prior to impact. The hips account for approximately 10% of the linear velocity

produced in the downswing, a direct result of peak hip torques at the transition between

the backswing and the downswing. Foxworth et al. (2003) demonstrated that the

correlations between club-head velocity and peak hip torques during the backswing were

r=0.64 (p=0.002), r=0.56 (p=0.01), and r=0.56 (p=0.01) for internal rotation, flexion, and


adduction, respectively. During the initiation of the downswing, the correlation values

were r=0.60 (p=0.005), r=0.46 (p=0.042), and r=0.09 (p=0.712) for external rotation,

extension, and abduction, respectively. Limitations and dysfunctions that negatively

affect a golfer’s swing can be observationally analyzed and corrected to create the proper

biomechanical balance needed to swing more effectively.

Trailing Hip Limitation & Dysfunction

An indication of limited external pelvic rotation in the trailing hip of a right-

handed golfer is an anterior tilt of the pelvis as the result of increased hip flexion.

Relative right hip internal rotation during the backswing of less than 30 degrees will

cause the pelvis to ascend and shift laterally to the right. This lateral shift reduces the

amount of club-head speed available following the backswing transformational zone. A

common compensation for this dysfunction is a toeing out of the feet of 10–20 degrees as

a means to promote proper hip coiling (Hume et al., 2005). The rotation of the pelvis to

the left into the downswing occurs prior to the arms and shoulders completing the

backswing. This forces the right hip into external rotation during axial loading and drives

the femoral head anteriorly, over time, this action can result in anterior capsular laxity,

elastic changes of the iliofemoral ligament, acetabular labrum tears, and frequently

chondral delamination (Torry et al., 2006). In addition to injuries, trailing hip limitations

create a reduction in club-head velocity.

Golf-related injuries. Cabri, Sousa, Kots, & Barreiros (2009) determined that

injuries sustained from playing golf originate from overuse or from traumatic causes.

Between 25.2 and 62.0% of all amateur golfers are injured on an annual basis, primarily

occurring at the elbow, wrist, shoulder, and dorso-lumbar sites. Studying 643 amateur


golfers, Gosheger et al. (2003) found that 255 reported a total of 527 injuries. These

injuries resulted in a total of 18,221 lost days of golfing and were mostly related to

overuse or trauma. The most common regions of the body affected by injury in amateur

golfers were the elbow, back, and shoulder, respectively. Injuries to the trailing hip

were found to be far less common, resulting in only 20.5 days of golf lost over a period of

two golfing seasons. Comparatively, thoracic spine injuries resulted in 137.4 days lost,

elbow injuries resulted in 73.8 days lost, and ankle/foot injures cause an absence of 55.9

days. Because of biomechanical stresses placed on the musculoskeletal tissue, different

phases of the golf swing may cause different patterns of injury, especially when

anomalies of posture and technique are present.

Analysis & Interventions

In order to determine any biomechanical limitations in the golf swing, a

functional movement analysis using qualitative biomechanics, or observation, should be

performed. This qualitative analysis is used to evaluate the biomechanical effectiveness

of the golf swing and to provide appropriate feedback in order to develop an intervention

for musculoskeletal limitations. Based on biomechanical principles, a theoretical model

of swing phase transitions should be performed and then compared with the observed

golf swing. Through analysis of this comparison, causes of any deficiencies can be

determined. The analysis is focused first on the swing as a whole before it is then applied

to the individual swing phases (Hume et al., 2005). Any range of motion or strength

dysfunctions can be addressed with specific exercise interventions.

Intervention programs. Increasing flexibility has conventionally been stressed

in golf specific exercises as a way to improve range of motion throughout the swing.


Improved flexibility allows for more mechanical work to be achieved throughout the

swing, therefore increasing club head speed at impact (Gordon, Moir, Davis, Witmer, &

Cummings, 2009). Sell et al. (2007) examined the strength, flexibility, and balance

characteristics of highly proficient golfers. The study determined that lower handicap

golfers had significantly greater isometric strength, as measured by a Biodex System 3, in

right hip abduction, right hip adduction, and left hip abduction. The lower handicap

golfers also demonstrated significantly greater range of motion, as measured by a

standard goniometer, in right hip extension, left hip flexion, and left hip extension.

Keogh et al. (2009) determined relationships between flexibility, muscular strength and

endurance and clubhead velocity in low and high handicap golfers. The results suggested

that low handicap golfers generated 12% greater club-head velocity, 28% greater golf

specific cable wood chop strength, and 30% greater bench press strength, but 24% less

right hip internal rotation strength. Lephart et al. (2007) examined the relationship

between range of motion and golf performance, as measured by club-head velocity. The

study examined the effects of an eight-week golf-specific exercise program to improve

range of motion, including the hip motions of flexion, extension, abduction, and

adduction. The training program included stretching exercises and both concentric and

eccentric strengthening exercises aimed to increase balance and hip strength while

improving hip flexibility. At the end of the program, the measured hip ranges of motion

exhibited significant improvements. These improvements resulted in increased clubhead

speed, ball speed, carrying distance and total ball distance. The varying factors that were

also affected by this exercise program must be taken into consideration. It was concluded

that flexibility and strength improvements lead to a 5.2% improvement in clubhead


velocity. These analysis techniques and interventions can be used to limit and or

overcome joint dysfunctions that arise during the golf swing. They also provide a means

to improve biomechanics throughout the swing and to improve golfer performance.

Client History/Review of Systems

The client was a 42-year-old male client referred to outpatient fitness training

after consultation from a sports medicine specialist. Prior to his referral, the client

reported having bilateral hip pain and decreased bilateral hip range of motion. Diagnostic

imaging reports from the sports medicine specialist were unremarkable. During his

initial fitness assessment, the client also reported a decrease in his golf handicap index.

Aggravating factors were identified as prolonged sitting, prolonged walking, bilateral hip

internal rotation, which was required for golf activities, playing golf for longer than one

hour, and swinging his driver, 3-wood, 5-wood, 4-iron, and 5-iron. He also stated that he

has been symptomatic for at least six months and that he has not played any golf for at

least three. Alleviating factors included the use of ibuprofen, short rest periods, and heat,

as per patient self-report. Comorbidities included history of low back pain and left knee

pain, as reported by the client. He had not received any previous interventions prior to

initial fitness training evaluation. The client’s primary goal for golf fitness training was to

be able to resume his previous golfing activities, which included playing at a higher level

and completing multiple rounds over a three-day span without reports of symptoms.

Clinical Impression

Based on the subjective data provided, this client was a candidate to undergo a

functional golf specific functional assessment to determine whether he would be

appropriate for this approach. Qualifying factors included: bilateral hip pain and


decreased bilateral hip range of motion, decreased club head speed, self reported fatigue

following a round of golf, and an increase in golf handicap index. In addition to the golf

specific functional assessment, further examinations to determine appropriateness of this

client included objective range of motion (ROM) measurements of his bilateral hip

flexion and bilateral hip internal rotation, as well as manual muscle testing (MMT) of his

bilateral hip flexors, and hip internal and external rotators and a Numeric Pain Rating

Scale (NPRS) for bilateral hip pain.

Examination

Tests and Measures

Functional screening. The initial examination was initiated with a Titleist

Performance Institute (TPI) Screen to determine the client’s fitness handicap. A TPI

Certified Level 3 Golf Medical and Fitness Professional administered this golf specific

functional screen. The TPI medical certification gives medical professionals golf-

specific injury assessment and rehabilitation techniques. These professionals examine

how to access and treat injuries and how specific physical limitations can be addressed to

improve performance. The TPI Screen consists of sixteen separate assessments that are

subjectively measured and used to establish a baseline golf fitness level. Assessment

descriptions and initial findings are provided in Appendix A. The findings of the TPI

screen were based on the client’s ability to do the movements, as well as the quality of

the movement patterns. The sixteen movements that were assessed included: (1) pelvic

tilt test, (2) pelvic rotation test, (3) torso rotation test, (4) overhead deep squat test, (5) toe

touch test, (6) 90/90 test, (7) single leg balance, (8) the latissimus dorsi test (shoulder

flexion test), (9) lower quarter rotation test, (10) seated trunk rotation test, (11) bridge


with leg extension test, (12) cervical rotation test, (13) forearm rotation test, (14) wrist

hinge test, (15) wrist flexion test, and (16) wrist extension test.

Hip active ROM. Hip flexion ROM was performed in the supine position using

a Jamar E-Z Read 12 ½” goniometer. Hip internal and ROM were performed with the

same goniometer in the sitting position. For all ROM measures, the client was asked to

move as far as possible through the range. Initial and follow-up ROM findings are

provided in Table 1. At the initial evaluation, active ROM measurements were recorded

for right and left hip flexion and internal rotation. The client produced 90 degrees of

right hip flexion, 15 degrees of right hip internal rotation, 60 degrees of left hip flexion,

and 22 degrees of left hip internal rotation. According to the American Academy of

Orthopedic Surgeons, normal range of motion values for flexion and internal rotation are

120 degrees and 45 degrees, respectively. Manual goniometers generate good test-retest

reliability and are the first choice tool for assessing hip ROM in the clinic. Test-retest

reliability coefficients have been shown to be above 0.90, while concurrent validity

coefficients ranged between 0.44 and 0.94 (Nussbaumer et al., 2010).

Hip MMT. Manual muscle testing was used to assess bilateral hip strength in

flexion, internal rotation, and external rotation. The client was tested in a seated position

with his back supported and pelvis stabilized by the chair. The client also placed his

arms across his chest during testing. The values of the initial and follow-up MMT are

provided in Table 1. At the initial evaluation, right hip flexion was recorded as 4/5

(good; holds test position against moderate pressure). Right hip internal rotation was

recorded as 3+/5 (fair +; holds test position against slight pressure. Right hip external

rotation was recorded as 4-/5 (good -; holds test position against slight to moderate


pressure). Left hip flexion, internal rotation, and external rotation were all recorded as 4-

/5 (good -; holds test position against slight to moderate pressure). MMT has

demonstrated good reliability for assessing hip muscle group strength, and is a consistent

evaluation tool (Wadsworth et al., 1987).

Numeric Pain Rating Scale. The client was asked to rate his pain intensity for

hip pain symptoms at the conclusion of a round of golf, using the Numeric Pain Rating

Scale (NPRS) (Figure 4), ranging from 0 (no pain) to 10 (worst pain imaginable).

Figure 4: Numeric Pain Rating Scale

At the initial evaluation, the client reported his pain to be 5/10 (moderate) for both his

right and left hip. Initial and follow-up pain intensity scores for hip pain symptoms are

provided in Table 1. The clinically important difference for the NPRS has been shown to

be a reduction of 2 points (Farrar et al., 2001).


Table 1. Physical Examination Key Findings:

Test or Measure Initial Examination Follow-up Examination (8 wk)

Right hip active ROM, deg Flexion 90 90 Internal Rotation 15 32 Left hip active ROM, deg Flexion 60 82 Internal Rotation 22 38 Right hip MMT Flexion 4/5 4+/5 Internal Rotation 3+/5 4/5 External Rotation 4-/5 4/5 Left hip MMT Flexion 4-/5 4+/5 Internal Rotation 4-/5 4+/5 External Rotation 4-/5 4+/5 NPRS hip pain (0-10) Right hip 5 1 Left hip 5 1

Clinical Impression

Based on findings from the initial examination, the client in this case report is

appropriate for implementation of an eight-week, golf specific exercise program to

improve bilateral hip ROM and to reduce subjective symptoms. The TPI Golf Medical

and Fitness Professional who administered the initial examination also implemented the

specific exercise protocol, oversaw the progress of the client throughout the eight weeks,

and executed the follow-up examinations. The outcome of this intervention plan was

determined by an eight-week follow-up TPI screen, as well as objective measurements of

the client’s ROM of his bilateral hip flexion and internal rotation. The follow up

objective measurements also included MMT of the client’s hip flexion and internal

rotation.


Intervention (Application of Theory to Practice)

Based on the findings of the initial TPI Screen (Table 1), subsequent treatment

sessions focused on implementation of an exercise prescription intervention with

components targeting (1) bilateral hip musculature weakness and (2) decreased bilateral

hip ROM. To address these deficits, the therapeutic program consisted of ten dynamic

exercises as described in Appendix B. The ten golf specific exercises prescribed were:

(1) 25-25-25, (2) comerford hip complex, (3) flow row, (4) burpee advanced, (5) med-

ball straight arm tornadoes, (6) deadlift with dumbbells, (7) lift-resisted rotation split

stance, (8) chop-cable resisted two arms two handles split stance, (9) two-arm cross body

latissimus dorsi stretch, and (10) hip rotation mobilization with movement. The 25-25-25

exercises provided a dynamic warm-up for the client before performing the remaining

nine exercises. The client performed all exercises three times per week, with the

guidance of a TPI Golf Medical and Fitness Professional. For weighted resistance

exercises, a 5% increase in load was applied when the client was able to perform the

workload for 2 repetitions over the desired number on two consecutive training sessions

(ACSM, 2009).

Outcomes

The client attended 24 treatment sessions over the course of 8 weeks, in addition

to the initial and follow-up examinations. Outcomes were recorded at the initial

evaluation and after completion of eight weeks of training (Table 1). At the follow-up

examination, the client’s active right hip flexion was unchanged. His right hip internal

rotation improved from 15 degrees to 32 degrees. Active ROM for left hip flexion

improved from 60 degrees to 82 degrees, and left hip internal rotation improved from 22


degrees to 38 degrees. All of the recorded MMT improved bilaterally in flexion, internal

rotation, and external rotation. Right hip flexion strength improved from 4/5 to 4+/5

(good +; holds test position against moderate to strong pressure). Right hip internal

rotation strength improved from 3+/5 to 4/5 (good; holds test position against moderate

pressure). Right hip external rotation improved from 4-/5 to 4/5. Left hip strength for

flexion, internal rotation, and external rotation all improved from 4-/5 to 4+/5. The

client’s golf handicap index was not assessed at the completion of eight weeks. The

United States Golf Association requires 20 rounds of golf to be calculated, and the client

did not participate in enough rounds of golf after the conclusion of the eight weeks of

training for a handicap index to be calculated (U.S.G.A., 2015). At the follow-up

examination, the patient reported improvement from 5/10 to 1/10 of bilateral hip pain

intensity at the completion of a single round of golf.

Discussion

This case report described how a golf specific functional assessment could be

used to prescribe and implement an exercise prescription intervention plan to improve

golf performance. At initial examination, the client’s right hip active internal rotation

was only 15 degrees. Relative right hip internal rotation during the backswing of less

than 30 degrees causes the pelvis to ascend and shift laterally to the right. Hip mobility

accounts for approximately 10% of the linear velocity produced in the downswing, and a

lateral shift reduces the amount of clubhead speed available at the start of the downswing.

Following the 8-week intervention program, the client’s right hip active internal rotation

improved to 32 degrees, an improvement of over 53%. Left hip active internal rotation

improved from 22 degrees to 38 degrees, an improvement of over 42%. The client also


demonstrated improved bilateral hip strength for flexion, internal rotation, and external

rotation. Though this study did not exam specific golf performance measurable, such as

clubhead and ball speed, a previous study by Sell et al. (2007) showed that an 8-week

training program that improved hip strength and flexibility resulted in improved clubhead

speed, ball speed, carrying distance, and total ball distance. Future studies will benefit

from a follow-up TPI functional screen to monitor any improvements in the client’s golf

fitness level and to assess clubhead speed or golf handicap index before and after 8-week

intervention program.


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Appendix A: Titleist Performance Institute (TPI) Screen: Assessment 1: Pelvic Tilt Test Question: What is their starting Pelvic Tilt? Answer: Neutral Findings: You have a good neutral pelvic posture at set up. This is good for proper muscle stabilization during the swing and will help transfer energy from your lower body to your upper body. Question: How was their Amount of Movement? Answer: Normal Pelvic Tilt. Findings: You can perform a standing pelvic tilt, which demonstrates good mobility in your lumbar spine and good control of the muscles that help position the pelvis during the golf swing. This should help you shift your pelvis into a stable position to help stabilize the large rotary force used to fire the upper body during the golf swing. Question: What is the quality of their movement? Answer: Smooth Motion Findings: You demonstrated good motor control with smooth movement when asked to tilt your pelvis back and forth in golf posture. This is a good sign that you will be able to control the motion of your pelvis in the golf swing. Assessment 2: Pelvic Rotation Test Question: How was their Pelvic Rotation without help? Answer: Limited Bilaterally Findings: You have difficulty rotating your lower body independent of your upper body. This can prevent you from initiating the downswing with a proper sequence and limit the coil between your upper and lower body. Question: If you had to hold their shoulders - what happened? Answer: Both Directions Improved Findings: You have the ability to rotate your lower body independent of your upper body, but only with someone else holding your upper body still. This means you have a stability problem in your upper body. Question: How was the Coordination of the Movement? Answer: Good Rotary Motion Findings: You have good coordinated control of the muscles that rotate your lower body independently from your upper body. This is important for proper sequencing in the golf swing.


Appendix A: Titleist Performance Institute (TPI) Screen (Continued): Assessment 3: Torso Rotation Test Question: How was their Torso Rotation without help? Answer: Limited Bilateral Findings: You have difficulty rotating your upper body independent of your lower body. This can lead to excessive lateral sway during the backswing, loss of trunk posture during the backswing, and faulty swing planes. Plus, it can cause your hips to outrace your trunk during the downswing and cause you to come out of your posture. Question: If you had to hold their hips - what happened? Answer: Both Directions Improved Findings: You are good at stabilizing your lower body and rotating your upper body independently in both directions. This is important for creating power and maintaining a good spine angle between your upper and lower body during the swing. Assessment 4: Overhead Deep Squat Test Question: How was their Overhead Deep Squat? Answer: Arms Crossed Full Deep Squat Findings: It is tough for you to perform a full deep squat while keeping your heels on the ground and a club over your head. But when you lower the club you can now perform a full deep squat. This is due to restrictions in your upper spine and/or shoulder flexion. This is a key indicator for your ability to maintain good posture at the top of your backswing. Because of this limited range of motion, maintaining a flexed posture from the waist down while elevating your arms during the backswing can be difficult. Question: How was their Half-Kneeling Dorsiflexion Test? Answer: Good Dorsiflexion Bilateral Findings: You have good flexibility in both calves. If there is any limitation in your squat mechanics it is probably due to your core muscles not stabilizing your pelvis properly during the squat. To maintain or develop a better squat, focus on core stabilization exercises while trying to perform a good deep squat. Question: How was their Weight Distribution? Answer: Their weight is evenly distributed during the squat. Findings: You do a great job of evenly distributing your weight between your right and left side during routine movements, like performing a squat.


Appendix A: Titleist Performance Institute (TPI) Screen (Continued): Assessment 5: Toe Touch Test Question: How was the Bilateral Toe Touch Test? Answer: Can't Touch Toes Findings: It is difficult for you to bend over and touch your toes with your knees locked. This can be due to a bilateral hip restriction or inflexibility in your lumbar spine, calves and hamstrings. These limitations can make it difficult to set up in a good golf posture and maintain that posture throughout you swing. Hip restrictions can make sitting into your right hip on the backswing and posting into your left hip during the downswing seem impossible. They can also lead to lower back and hip pain during golf. Question: How was the Unilateral Toe Touch Test? Answer: Both Limited Findings: It is difficult for you to bend over and touch your toes with your knees locked. This can be due to a bilateral hip restriction or inflexibility in your lumbar spine, calves and hamstrings. These limitations can make it difficult to set up in a good golf posture and maintain that posture throughout you swing. Hip restrictions can make sitting into your right hip on the backswing and posting into your left hip during the downswing seem impossible. They can also lead to lower back and hip pain during golf. Assessment 6: 90/90 Test Question: How far was their Standing External Rotation on the Right? Answer: Greater than Spine Angle Findings: The total external rotation in your right shoulder is over 90 degrees while standing tall. The average range of motion for players on the PGA Tour is over 90 degrees. You have good external rotation in your right shoulder, which should allow you to set the club and rotate your right arm into any position that you want during the backswing. Question: What was the difference in Golf Posture on the Right? Answer: Same as standing Findings: You maintain the degree of external rotation in your right shoulder when getting into your golf posture. Some people tend to lose their total range of motion in their shoulder due to lack of stability in their shoulder blades when bending from the waist. Question: How far was their Standing External Rotation on the Left? Answer: Less than Spine Angle Findings: The total external rotation in your right shoulder is less than 90 degrees while standing tall. The average range of motion for players on the PGA Tour is over 90 degrees. Since your range of motion is limited, you might have some difficulty in properly rotating your right arm during the backswing. Related swing faults could be flying right elbow, getting trapped or stuck on the downswing, loss of posture or an over-the-top swing plane. Question: What was the difference in Golf Posture on the Left? Answer: Same as standing


Appendix A: Titleist Performance Institute (TPI) Screen (Continued): Findings: You maintain the degree of external rotation in your right shoulder when getting into your golf posture. Some people tend to lose their total range of motion in their shoulder due to lack of stability in their shoulder blades when bending from the waist. Assessment 7: Single Leg Balance Question: How many seconds with Eyes Closed on the Right? Answer: 6-10 seconds Findings: We tested your ability to stand on your right leg only with your eyes closed. This was testing your overall balance on the right side of your body. You could only stand for 6-10 seconds before having to open your eyes. Over 16 seconds is considered good balance for the elite golfer. This limited balance on your right side can limit your ability to load into your right side or cause you to lose stability during the backswing. Question: How many seconds with Eyes Closed on the Left? Answer: 0-5 seconds Findings: We tested your ability to stand on your left leg only with your eyes closed. This was testing your overall balance on the left side of your body. You could only stand for less than 5 seconds before having to open your eyes. Over 16 seconds is considered good balance for the elite golfer. This limited balance on your left side can limit your ability to post into your left side or cause you to avoid your left side during the downswing. Assessment 8: The Latissimus Dorsi Test (Shoulder Flexion Test) Question: How many degrees on the Right? Answer: Covers the Nose Findings: You have approximately 120 degrees of flexion in your right shoulder. Normal range of motion on the PGA Tour is over 170 degrees. Any limitation in the right lat muscle or shoulder girdle itself can affect your ability to rotate your trunk around your lower body past impact and it can cause your right arm to be restricted through your finish. Question: How many degrees on the Left? Answer: Covers the Nose Findings: You have approximately 120 degrees of flexion in your left shoulder. Normal range of motion on the PGA Tour is over 170 degrees. Tightness in this area can lead to loss of spinal posture as the arms are elevated during the backswing. Plus, this can restrict your overall shoulder turn during the backswing.


Appendix A: Titleist Performance Institute (TPI) Screen (Continued): Assessment 9: Lower Quarter Rotation Test Question: How was their Backswing rotation? Answer: Limited Rotation on the Right Leg Findings: You have limited internal rotation on the right leg. Any reduction in internal rotation on the right leg can lead to an inability to rotate properly without losing posture on the backswing. Question: How was their Downswing Rotation? Answer: Limited Rotation on Left Leg Findings: You have limited internal rotation on the left leg. Any reduction in internal rotation on the left leg can lead to an inability to rotate properly on the downswing without coming out of posture through impact. Assessment 10: Seated Trunk Rotation Test Question: How far do they rotate Right? Answer: Equal to 45 degrees Findings: You have limited mobility rotating you thoracic spine to the right. Normal right rotation is over 45 degrees on the PGA Tour and you had exactly 45 degrees. This may limit you ability to get a full shoulder turn and maintain a good stable posture during your backswing. Question: How far do they rotate Left? Answer: Greater than 45 degrees Findings: You have good mobility rotating you thoracic spine to the left. Normal left rotation is over 45 degrees on the PGA Tour and you had over 45 degrees. This should help you get a full shoulder turn through impact and maintain a good stable posture during your swing. Assessment 11: Bridge with Leg Extension Test Question: What happened when their Right Leg was down? Answer: Right Glute was Normal Findings: You have good strength and stability in your right glute muscles. This will help you maintain good lower body stability in the backswing and power on the downswing. Question: What happened when their Left Leg was down? Answer: Left Glute was Normal Findings: You have good strength and stability in your glute max muscles on the left. This will help you maintain good pelvic posture and lower body stability during the downswing.


Appendix A: Titleist Performance Institute (TPI) Screen (Continued): Assessment 12: Cervical Rotation Test Question: How is their left cervical rotation? Answer: Can't rotate to Mid-Clavicle Findings: You have limited left rotation in your neck. Normal range of motion is over 70 degrees. This can limit your ability to fully rotate your shoulders during the backswing while maintaining a stable head and body posture. Question: How is their right cervical rotation? Answer: Can't rotate to Mid-Clavicle Findings: You have limited right rotation in your neck. Normal range of motion is over 70 degrees. This can limit your ability to maintain your posture during the downswing and fully rotate your shoulders through impact. Assessment 13: Forearm Rotation Test Question: How much total Forearm Pronation (Palms Rotating Down) do they have? Answer: Normal (Greater than 80 degrees) Findings: You have normal proation (rotating palms down) on both forearms. This will help you set and release the club properly throughout the swing. Question: How much total Forearm Supination (Palms Rotating Up) do they have? Answer: Normal (Greater than 80 degrees) Findings: You have normal supination (rotating palms up) on both forearms. This will help you set and release the club properly throughout the swing. Assessment 14: Wrist Hinge Test Question: How much total Wrist Hinge Up (Radial Deviation) do they have? Answer: Normal Bilaterally Findings: You have good hinge up (radial deviation) in both wrists. This will help you set the club properly during the swing. Question: How much total Wrist Hinge Down (Ulnar Deviation) do they have? Answer: Normal Bilaterally Findings: You have good hinge down (ulnar deviation) in both wrists. This will help you release the club properly during the swing. Assessment 15: Wrist Flexion Test Question: How much total Wrist Flexion (Bowing) do they have? Answer: Normal (60 degree or Greater) Findings: You have normal flexion (bowing) in both wrists. This will help you set and release the club properly throughout the swing. Assessment 16: Wrist Extension Test Question: How much total wrist extension (Cupping) do they have? Answer: Normal (60 degree or Greater) Findings: You have normal extension (cupping) in both wrists. This will help you set and release the club properly throughout the swing.


Appendix B: Specific Exercises:

10 Exercises Duration: 45 minutes – 1 hour

1) 25-25-25 3 sets

Description:

Perform 25 jumping jacks, 25 seal jacks and 25 sagittal-plane swings. Resistance: 0 Instructions: Switch to the next exercise after each set - jumping jacks first, seal jacks second and sagittal plane swings last.

Set Reps Sec. / Rep Sec. / Rest

1 25 1 5

2 25 1 5

3 25 1 60


Appendix B: Specific Exercises (Continued):

2) Comerford Hip Complex

Description:

Lie on your side with your knees bent and feet on top of each other. Keeping your feet in contact with each other, try to lift your top knee up as far as possible. Next, keep your knees together and raise the top foot away from the bottom foot and slowly return to starting position. This is simply a clam shell as described above, but in reverse. Next, split your knees apart and perform the reverse clamshell while keeping your knees approximately six inches apart during all leg movements. Finally, with knees split apart six inches, take top leg and move it backwards (extend) until the upper leg (femur) is in line with the spine and perform reverse clamshells. Repeat on opposite side.


1 1 90 30



3) Flow Row

Description:

Standing on your lead leg facing a cable cross machine and hold onto a cable cross handle with your trailside hand. Slow and controlled, rotate your entire trunk clockwise (away from the resistance) and perform a row at the end of the movement. Return to the starting position. Repeat on opposite leg. Instructions: Repeat in opposite direction


1 8 6 30

2 8 6 30



4) Burpee Advanced

Description:

Begin in a standing position. Drop into a squat position with your hands on the ground. Next, extend your feet back in one quick motion to assume the front plank position. Now, return to the squat position in one quick motion. Finally, return to standing position and jump in the air as high as possible. Repeat Set Reps Sec. / Rep Sec. / Rest

1 8 8 60

2 8 8 60



5) Med-Ball Straight Arm Tornadoes

Description:

Holding a med-ball out in front of your chest with your arms extended, try to rotate the ball back and forth as fast as possible. Set Reps Sec. / Rep Sec. / Rest

1 10 3 30

2 10 3 60



6) Deadlift with Dumbbells

Description:

Place the feet in a symmetrical stance approximately hip width apart and the head neutral and hold a dumbbell in each hand (resting against your thighs). Begin by taking the hips straight back with a slight knee bend while the shins remain vertical. Extend back until a quality and appropriate range of hip hinge is reached. Return to the starting position the exact same way using the hips to regain standing position. Be sure the head and neck are neutral and there is no rounding of the back.


1 12 5 30

2 12 5 30

3 12 5 60


Appendix B: Specific Exercises (Continued): 7) Lift - Resisted Rotation Split Stance

Description:

Attach one end of the tubing to a low point attachment. With hands separated and palms facing down grab the black foam of the FMT. Get into a split or lunge stance with your foot farthest from the anchor point forward. Both knees should be flexed. Hold hips directly under the trunk and spine erect with shoulders back. Pull up the tubing across the chest while keeping it close. Trunk should rotate and follow your hands throughout the exercise. Lower body should remain stable. The tubing should come across the body from shoulder to opposite hip, palms facing down. Tubing should be in line with closest arm. For more resistance, slide farther away from the point of attachment. Before starting your exercise, please make sure the point of attachment for the tubing is secure. Set Reps Sec. / Rep Sec. / Rest

1 12 5 15

2 12 5 30


Appendix B: Specific Exercises (Continued): 8) Chop - Cable Resisted Two Arms Two Handles Split Stance

Description:

Set both handles of the cable cross to the high position. Get into a split stance with your down knee away from the cable cross. Grab both handles with both hands and keep your posture as tall as possible. Perform a chop diagonally across your body keeping your hands close to your chest throughout the movement. Slowly return to the starting position. Repeat the appropriate number of sets and reps. Set Reps Sec. / Rep Sec. / Rest

1 12 8 30

2 12 8 30


Appendix B: Specific Exercises (Continued): 9) Two-Arm Cross Body Latissimus dorsi Stretch

Description:

Using a stretching pole, golf cart or other object for support, get in golf posture and place one arm on the object, then with the opposing arm stretch across your body applying pressure on the object to create a stretch in the latissimus dorsi and shoulder. This is good body prep for golfers that lose their posture due to tightness in the latissimus dorsi and shoulders. Instructions: This is a great stretch for those golfers that lose their posture during their swing or have difficulty with the correct pivot motion. Set Reps Sec. / Rep Sec. / Rest 1 5 5 30 2 5 5 30


Appendix B: Specific Exercises (Continued): 10) Hip Rotation Mobilization with Movement

Description: Set up a mobilization belt to wrap around the client’s proximal thigh and clinician’s hips. Clinician sits backwards into hip, providing a sustained grade I distraction. With sustained distraction, the client actively moves into the full available hip internal and external ROM. Set Reps Sec. / Rep Sec. / Rest 1 10 5 30 2 10 5 30

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Exercises(for(Improving(Hip(Rotation( - FLVC27397... · 2015-06-26 · Exercises(for(Improving(Hip(Rotation(USE OF GOLF SPECIFIC FUNCTIONAL ASSESSMENT AND EXERCISES FOR IMPROVING