When the X-Factor Becomes an Ouch Factor: Hip Mobility and the Modern Golf Swing

[00:00:00] Welcome back to Untold Physio Stories Podcast. It's Dr. E. Dr. Sean Wells and I are doing another asynchronous episode and this time Sean's talking about a hip case so I'll leave it up to him and then my reaction slash reply will be afterward. Hey Dr. E. It's Dr. Wells. Got another interesting case for us. This one is a young male golfer. He actually plays on one of the smaller tours.

[00:00:31] He's recently graduated from college and he's doing really well. He's trying to progress and get to the point where he can become a professional at the highest level and obviously that takes a lot of practice and a lot of time on the range and course. And so with the weather obviously in spring and moving into summer he's been hitting a lot of golf balls and so he came to me and said I'm having some right upper back pain.

[00:00:55] And obviously when I kind of like around the ribs and stuff and when I hear that I know you probably think the same thing that you get concerned about organ involvement particularly around like the ribs and that scapular area. So I had to go through pretty thorough medical screening to make sure that he didn't really have a lot of medical involvement.

[00:01:17] But one thing as I went through my review systems with him he mentioned is that when he was a child he had leg cath purse disease in his left hip. I said okay interesting. Obviously I'll take a look at your hip and see how it relates to your spine and your movement and your golf game and things. So having ruled out a lot of those possible medical scenarios because he's fairly young fairly healthy. I felt pretty confident this is probably movement related.

[00:01:46] So as we got into the exam I had him do a standard standard seated trunk rotation assessment. And he had some discomfort with rotation to the right. Obviously he had fairly good rotation. He's a golfer so he's doing a lot of rotation overall. And I would say his left trunk rotation was definitely better. It was closer to a full 90 whereas to the right it was slightly limited. Some of that could have been because of pain.

[00:02:17] As I looked at his side bending overall his side bending was slightly off. And part of that was as he was in standing I noticed he had a touch of scoliosis. And so just looking you know it appeared that his left leg was shortened up a bit. So obviously right side bending was more limited than left side bending. With a little bit of that shortening on the left side he tended to kind of lean just kind of slightly lean to the right just a touch.

[00:02:49] From there obviously with golf I said well show me your swing and I want to see your swing. And so he went through a few swings without a club just to kind of show me this is kind of how my swing path is. And I talked to him about some of the technicalities of what he's changed in his swing recently. And he said you know overall like I have to modify my swing a little bit because sometimes you know my left hip does bother me.

[00:03:14] And so he I kind of asked him you know tell me a little more about that. And he said that he's had to undergo a few treatments with his left hip a couple injections. Sometimes some dry needling sessions and physical therapy myofascial release techniques and things. He has been going to the gym which is great. So he's like I've been working on like my squats and my lunges and just trying to build up power. But I can't go real deep in my squats and I can't go real heavy. So I have to be really careful like with how much I load that left hip.

[00:03:44] So I will say then as a clinician I'm thinking right upper back pain. How does it even relate to his hip? Well my my big hunch is that with golf in particular as you go into your backswing your right hip goes into internal rotation. But your left hip goes into external rotation. And so as I go to examine him I say you know lay back on the table. I want to just see how much rotational motion you have in your hip. And he kind of laughed. He's like not much.

[00:04:13] And so as he goes to actually rotate his hip I'm only able to get him to maybe say 15 degrees of a hip external rotation. He's very limited. And then as I go into internal rotation it's also limited to I mean maybe a couple degrees at best. And I said wow you know you really don't have a lot of available rotational motion in your hip. He said I know. That's why I've had him make some swing modifications and things. And I said well I think you know maybe this is contributing to some of your right upper back pain. Right?

[00:04:42] And he said yeah overall what I'm I think what I'm trying to do is rotate and force myself more in the upper upper thoracic spine to get rotation to get behind the ball. To really develop that X factor. You know golfers develop power from the differentiation between their shoulders and their hips. And they call that the X factor.

[00:05:01] And that's in the modern golf swing so you have to really anchor their legs and then rotate a lot you know a lot from the upper spine to get that that sort of differential and twisting which creates a nice whipping motion. I talked to him I said well what about the more traditional swing like Sam Snead or Ben Hogan some of those older players that use a lot of leg motion you know where they lift the foot. And he's like yeah that just involves a lot of timing or big swing change right at a critical moment in my profession.

[00:05:30] And I said yeah hey listen I'm a physical therapist I'm not a technical golf coach so I'm not going to you know go and change your swing because that could be devastating for your your professional development and growth as a professional and to get in on the big tour. But I said you know obviously with your motion and your hip it is vastly limited so diving in closer around the tissues in that right upper upper thoracic spine.

[00:05:55] He had some obvious very tender trigger points you know poking them he's like he's like yeah that's really uncomfortable. So from there I identified particularly like in the longissimus area and even into some of the rhomboids he had some significant some significant pain response with just simple palpation. And I went and tested his upper extremity right upper extremity strong in his neck.

[00:06:21] I went ahead and had him do cervical motion side bending and extension and it was all clear. No referral pattern nothing in the right upper extremity at all. And so I provided him some treatment. I did some thoracic manipulations and then demonstrated to him you know obviously he knows how to get right rotation and into that whipping direction. But I think it's not he's kind of getting a double whammy with overload. He's forcing himself back into that rotation and then as he comes through and falls through.

[00:06:52] As you come through in a swing on in golf you're going into hip internal rotation. He doesn't have that much hip internal rotation. And so what ends up happening is he's over rotating. So with that over rotation he's he's he's getting a lot of eccentric forces through that right upper thoracic spine and particularly in the you know longissimus and some of the rotators and things. So I told him you're kind of getting a double whammy.

[00:07:18] You're getting that forced rotation to get behind the ball and then your muscles are having to really desolate you as you explode through because you can't really rotate through that left lower extremity as you post up. And so we talked about turning his left hip out more as he stands. But then the problem with that is you turn the left foot out in golf you limit how much external rotation you're able to get. So then you really can't get behind the ball.

[00:07:45] And so since he already had really limited hip external rotation as well I said that's not really a solution for you either. So it was a challenging situation and obviously I'm leaving out some of the exam too. I mean he had about almost a three-quarter leg lane discrepancy. He had a heel lift. So there was there's some of those other other factors there not just in the rotational plane. Obviously in the frontal plane there were some things too.

[00:08:10] But some of the tidbits that I walked away with was that you know he had done some good strengthening work but a lot of his strengthening work is very sagittal based. So I talked to him about working on things like side planks and so actually tested his hip abductors on that side. And they were about 40 percent weaker than his opposite side. So I told him you know some of the pain response and things you're having and you know limited motion is probably causing inhibition there.

[00:08:36] So that might also affect your ability to post up onto that left side and really control your swing through. So showing him that was important I think also with training. I talked to him about doing you know rows and really being able to tolerate the eccentric forces of that forceful downswing and follow through. And so he'd said a lot of what the rowing motion he had been doing was just really strict linear kind of pulls.

[00:09:03] And I said well you might want to consider adding some single arm rows and we're really focusing on on that good trunk rotation both like concentric and eccentric particularly during offseason. Obviously during season he's already overloading the tissue and they're probably getting too much. But I said to build up resiliency maybe looking at from a periodization sort of standpoint. Don't hit it right now right as you're about to like qualify for the pro you know the pro card qualifications.

[00:09:30] But when you go into offseason or you have a break you're able to recover a bit and you can start loading. That's that's what I would recommend working on. And so kind of addressing some of those rotational so transverse and frontal plane weaknesses were also really important I think for him. But overall it's an interesting case he knows that somewhere down the road there might be a hip replacement coming his way particularly if he's going to stay on the tour for a while.

[00:09:54] And I try to encourage him that it might actually help him but he's fairly young and so having that surgery now would set him back in terms of qualifications and things. But you know I told him that his hip motion is you know markedly limited but it's amazing how well he's still able to function. So anyhow interesting golf case and I'd love to hear your thoughts. I'd love to hear who else works with golfers what their thoughts are on this case.

[00:10:19] And Dr. Ian I'd love to hear your input too is like kind of what you would have done differently too especially for a spine case. Hey Sean thanks for that case it's really cool. It reminds me real quick of a case where when I first learned the SFMA it was in a division one javelin athlete and he had medial elbow pain.

[00:10:44] And a lot of it was a result of a lack of trunk rotation to the right as he was a right arm thrower and hip and tibial rotation on his planting side. So he had lack of hip IR and tibial IR and that planting side and also dorsiflexion.

[00:11:04] And when we improved that along with his right trunk rotation his elbow pain went away because that was probably just a stressful point in that chain. And it sounds like this young gentleman is having similar issues. I like the way you went about it especially addressing strength in the frontal plane. I think that's missed in a lot of a lot of traditional training.

[00:11:29] Um I'm wondering why or um maybe I would have incorporated some uh rotational strength training too. Maybe med ball slam starting with paloff press if uh he can tolerate it or isometrics uh multi-angle isometrics sustained um especially to kind of cement that new trunk rotation.

[00:11:49] I probably I'm not sure what you gave him for uh resets for recovery plan um after restoring his right trunk rotation with the thoracic manipulation. I assume that's what happened um you didn't really say but I I kind of figured that would happen. Um I'm expecting some asymmetries due to the scoliosis but we could always just improve what we have. Uh probably would have given him thoracic whips as a warm-up.

[00:12:13] And I'm also curious as to potentially why um he didn't do something like corkscrew or mobilize his left hip. Was it because of leg calve perthus disease? Um gosh I probably butchered that. But I probably would have tried some of the corkscrew technique I taught in my course to try to improve overall hip mobility. And then have him work on that rotation.

[00:12:40] I'm also curious usually when I find with a scoliosis and marked hip uh ER limitation. I know he had marked hip IR and ER limitation on the left. But sometimes I find especially with a bony end feel of excessive limitation of ER on say the left side. It would be IR on the right side.

[00:13:01] Also it's a bony end feel meaning that potentially as a kid they instead of set W sit they would sit like half W sit as an excessive ER on one side. Excessive IR on the other. And uh that's just how they developed. I don't know. I find that normally when one hip is limited that in one direction the other hip may be limited in the other direction. And particularly with bony end feels then I figure that you can't really change. You might be able to change a pain response but not really change at least the motion dramatically.

[00:13:31] With his case again you didn't make a you didn't tell me in the assessment whether it was a bony end feel. Whether you tried to mobilize it because again I know the difference between bone and tone. But sometimes I get surprised that I think it is a bony end feel as in we can't rapidly change it. But then I try something like the corkscrew and it actually changes. So then that would be a tone instead of bone response. And then that means that they could actually work on it as well.

[00:13:57] But overall it sounds like he's in good hands and it's good that you didn't try to change his stroke. Just because that could be detrimental to his career. And again just like me we are not professional golf coaches. So listeners let us know what you think of this case. And if you find it interesting if you guys work with golfers or you would have done anything different. Or looked at anything else. Please rate Untold Physio Stories 5 stars wherever you listen to podcasts. As that helps our discoverability.

[00:14:27] And as always you guys have a great day.