Case Report - Journal of Physical Therapy and Sports Medicine (2018) Volume 2, Issue 1

Managing a male golfers low back and sacroiliac joint pain using manual therapy and therapeutic exercises to avoid surgery and continue scratch level play.

*Corresponding Author:

Dr. Stephen A. Black
Department of Rehabilitation Sciences Marieb
College of Health & Human Services Florida
Gulf Coast University Fort Myers, FL 33965, USA
Tel: 239-590-1281
E-mail: sblack@fgcu.edu

Accepted date: April 7, 2018

Citation:Black SA. Managing a male golfers low back and sacroiliac joint pain using manual therapy and therapeutic exercises to avoid surgery and continue scratch level play. J Phys Ther Sports Med 2018;2(1):33-39.

Abstract

Purpose: The purpose of this case study is to demonstrate a unique way of working with low handicap golfers looking to avoid surgery after two years of low back/sacroiliac pain (LBP/SIJP) and injury. This study used all-encompassing treatment sessions each time the patient was seen, including lengthening, strengthening and creating power with less stress on the LB/SIJ region. The treatment looked at decreasing muscle and structural imbalance and engaging all of the muscles when making a swing. Client description: Patient is a 71 year-old man with a 14 month “bad” back with history of pain. The pain was so debilitating that he went from daily play to a three time a week play. His play itself also decreased from a +2 handicap to a -4 handicap. The patient complains that he suffers from constant pain and has decreased all functional and recreational activities. Intervention: Patient was seen 2-3 times a week for eight and half months. There was a three-month stop when the patient returned north for the summer and was healing from an arm injury. The patient completed treatments targeted at maintaining a level pelvis, increasing mobility of the lumbar spine, and strength training all surrounding core, gluteal and lower extremity muscles. Muscles Energy Techniques (MET) were used to align his pelvis. Stabilization exercises and strengthening exercises that could be completed in the golf position were done in order to create proper length tension relationships as well as kinesthetic awareness of the body during the swing. Balance and proprioception was also worked on every session with a push/pull concept in order to decrease muscle imbalances and increase coordination from past months of pain and injury. Measures and Outcomes: All measurements and subjective and objective measures were covered over 8 months. After the second treatment patient's pain level and ability to move independently was improved significantly. IR and ER of the hips took the longest to achieve but this measurement directly affected the pelvis alignment and patient’s subjective comments on the ability to get through the ball during the swing. His pain and tone levels continued to go down throughout treatment and he is now without pain during and following play. Implications: “Once a bad back, always a bad back” appears to be a proper theme for athletes who wish to continue to play at the same level or better without surgery or medicine intervention. Patients who are willing to work on their body with manual and physical strength training can keep most symptoms in control and still have improvement in play. But it requires daily exercise and manual stretching. Pain was decreased and function was returned in about 25 days, but whenever the patient stopped his exercises and stretching (within the first 5 months of treatment), symptoms would return. He is now able to play and travel with less routine, but still needs at least 1 time a week for core strengthening and stretching. Golf mechanics have been resumed because there is a lack of pain and all the muscles that should be used are now turned on with the specific strength routine.

Introduction

LBP and SIJ dysfunction are two of the most common golf related symptoms representing up to 52% of all musculoskeletal complaints/injuries [1]. Because LBP is already costing the nation over $50 billion dollars a year to treat, it is vital to come up with ways to prevent or decrease LBP and SIJ dysfunction among golfers so that there is not more money spent nationally to deal with these pathologies [2].

Injury to a specific area still affects the entire body. Proprioception (the unconscious knowledge of where the body is in space) can be lost if an injury is sustained. The longer the patient is not playing, the greater the loss of the proprioception and kinesthetic awareness. In addition, coordination will also be lost and timing of the mechanics will be off, decreasing patients overall ability to play and score well. Once a golfer shortens his stroke and loses their timing, the harder it is to return to same level play.

Back pain is common among golfers due to the fact that the golf swing requires many complex movement patterns with coordinated muscle contractions and nerves firing in proper sequence [3]. With the complex movements needed to complete a full golf swing, one must understand that back injury is rarely the primary cause of LBP. Dr. Greg Rose has researched why low back injuries are not the primary cause of pain but rather secondary to the massive amount of rotational mobility that is needed in the thoracic spine and hip region. The lumbar spine actually only flexes and extends and is not created to rotate at the facet joints. But at times the lumbar spine is forced to be the primary rotator due to the lack of mobility in the thoracic spine and hip region. In addition, golfers who lack ankle and shoulder mobility also increase lumbar strain [3]. So in reality, injuries to the spine are caused from limitation of movement of other parts of the body and these areas must be addressed if a patient wishes to decrease the risk for re-injury [4].

It is vital that the swing mechanics are reviewed and corrected in order to minimize lumbar pathologies and overuse injuries. The most common swing faults that are seen are reverse spine angle, s-posture, and hanging back [4]. These faults put undue stress on the lumbar spine and SI joints. There are many different swing mechanics, but we are not looking at that, rather we are looking at the tightness and restriction of the muscles in the body that cause the LBP and SIJ dysfunction, and how to remedy these limitations so players can continue to play at their current golf level [1].

Biomechanics of the human body affect how muscles can strengthen and change with training. For athletes it is important for muscles to have the proper length tension relationship in order to perform at an elite level. It has been researched that golfers suffer from a muscle imbalance between lead and trail side of the body, as well as range of motion in the joints.

Case Description

History

On arrival to therapy this 71 year old male patient was convinced that he was destined to have a fusion of the L4-L5- S1 bilaterally. He was defeated, in pain and discouraged since the bilateral epidural injection that he had 10 days ago was unsuccessful. The patient had been suffering from “bad” pain for the past 14 months and his play of game was suffering. Patient complained of inability to sleep more than 4 hours without waking from pain and having a 6-8/10 pain with all activities. Patient was under better control as long as he took anti-inflammatory medicines. Patient presented with an unlevel pelvis; supine to long sit test was completed and was positive. Left leg appeared longer in supine and shortened upon long sit. MET was used to re-align the pelvis. Next the patient performed the Selective Functional Movement Assessment (SFMA). Eighty percent of all the completed tests were graded as dysfunctional with pain. The most important test that was completed on evaluation day (and every other treatment day) was IR and ER of the hip in supine and standing. Supine revealed limitations bilaterally 20-22 degrees both ways, which was possibly the main cause of patients LBP and SIJP. Standing test revealed pain in both hips regardless of which leg was in high step position or standing and in both directions. Hip windshield wipers were very challenging and painful as well.

Findings

It was apparent that two years of pain and injury had altered which muscles fired and worked with the swing. As we continued to work on strength and length of the patient’s body, we figured out that new injuries and lack of playing caused a “lazy” swing. With hours of training, strengthening, stretching and manually correcting the length tension relationship of the core, lumbar and gluteal muscles, the patient returned to playing pain free. It was learned that the patient must continue with strengthening and stretching weekly in order to maintain his current level. Patient has not needed or had another epidural injection and has not returned to the orthopedic surgeon for any discussion of fusion of the lumbar spine. Muscle tissue is now normalized and patient is able to complete new exercises at different intensities with no detriment to his overall play. Patient has also returned to scratch play according to GIN handicap scoring, with a goal to return to his +2.

Intervention

The patient was seen 2-3 times a week for 8.5 months with a 3- month stop with HEP. After all of the evaluation tests were completed and information was known about what was tight and what was weak, the process began.

It is important for the patient to understand what is going on in the body. The lack of proprioceptive knowledge of the body is potentially the worst component in a golfer. With an injury and a general lack of body knowledge there is an increased risk for more secondary injuries. Therefore all sessions conducted had some form of re-education and engagement of muscles working on proprioception, balance and kinesthetic awareness.

SIJ level was assessed each time pre and post treatment session in order to maintain proper alignment for strength training and relief of pain. Patient was taken through passive pelvic tilt movements in quadruped to re-learn the motion as well as increase mobility of the lumbar spine, while stretching the anterior capsule of the hips. LB mobility was further assessed in each treatment with PA glides to make sure they were smooth and decreasing in pain. Lower extremity flexibility focused on IR and ER of the hips and was done manually to avoid patient using other muscles. IR and ER limitation in golfers can be [5]. When patients lack 0-45 degrees of motion they are at increased risk for LBP and arthritic changes in the hip joints. This is very damaging to the lead hip in a golfer.

Each session included exercises and manual work discussed above but in varying order so that there was no muscle memory. Patient saw an increase in function within about 30 days. Patient had less pain and more stability and strength to maintain position when swinging the club. The detailed exercise routine is attached listing all exercises that were completed throughout the 8 months of care (Table 1).

Table 1. Manual work that was completed.

At the end of the season when the patient was about to gear up for a senior tour event, he had an unrelated golf injury where he tore his right brachioradialis muscles and tendons picking up a piece of luggage. This did decrease his ability to play but we continued with the lower body exercises and the patient did play in the event. Once the event was over the patient took some time off to heal the arm. This caused a significant change in his overall play when he returned to golf 2.5 months later. As documented by Dr. Greg Rose, golfers that have injury to the right arm often increase the stress to the opposing hip. When the patient returned to play he was demonstrating a “lazy” swing where he was unable to get his arms into position. He was unable to supinate his arms and bring the club back with the face of the club in the correct position (it was closed) therefore he was not using his lead hip to push through the swing. This left a lot of the strength and power out of the swing, causing the injured arm to work harder and the swing to almost get “stuck” so the patient was unable to get through the swing. This caused more strain and pain in the low back region. Once the lazy swing was seen, a new focus was created on rotational push exercises and more engagement of the quadriceps. Patient showed very week quadriceps strength 3+/5 with unilateral lift step test of the quadriceps. This weakness deceased the patient’s ability to maintain a good address position and stay down in the swing with power through the adductor of the lead hip.

Multiple new exercises were completed to assist in reeducating the lead hip adductor muscles to contract and assist in pulling the right arm through the swing. Punch turns with the hip leading were also completed and this allowed the patient to feel the power of those muscles again. Squat chop turns were used to elongate and create coordinated movements to strengthen the quadriceps, adductors and quadratus muscles bilaterally. Multiple exercises were completed, and no two workouts were the same. The difference with this type of treatment is to work the body in so many different angles that all muscles are reactivated during the swing and play. All sessions ended with manual work to lengthen the muscle tissues in the legs, gluteal and lumbar spine (Table 2).

Table 2. Exercises that were completed.

All measurements and subjective and objective measures over the 8 months are outlined in Table 3 in above section. After the second treatment patient's pain level and ability to move independently was improved significantly. IR and ER of the hips took the longest to achieve but this measurement directly affected the pelvis alignment and patient’s subjective comments on the ability to get through the ball during the swing. His IR/ ER on initial evaluation was 20-22 degrees and now is 38-40 bilaterally. The patient’s pain was reduced 50%within 2 weeks of working on muscle length and tone. His pain and tone levels continued to go down throughout treatment and he is now without pain during and following play. Muscle engagement or contractions now decrease any new pain that arrives following play. Isometric contractions complete during play and in address position have assisted with kinesthetic awareness and feeling of getting through the ball without getting “stuck” in the back swing. Patient is now able to complete the pelvic tilt test in quadruped, standing and in address position, which is a great kinesthetic awareness return post injury. This patient has had an excellent outcome that came from hard work. He must continue with manual stretching and massage, as well as strength training all angles of the body, in order to maintain this level of play. It is not without extra time and fees that this pain will stay away. This is his new routine that he must continue to maintain his level of scratch level play.

Table 3. Measures and outcomes of case study.

Discussion

The purpose of this case study was to look at how we can better manage our patient’s pain and disabilities while avoiding injections and surgeries and allowing them continuation of play. It was important to first educate the patient on life after spinal fusion surgery compared to golf play without surgery. Spinal fusion is a significant surgery that would have limited the patient from swinging a club (not actually playing) for 8-12 months post-surgery [1]. To an athlete this can be seen as a death sentence. So it was very important to educate the patient on the pros and cons of both directions for treating his back pain, and to get the commitment to treatment that was needed to avoid this surgery and continue to play.

All evaluations start with assessing the patient to determine their needs and limitations to make sure they are safe to resume play and to participate in a full-scale multi-dimensional exercise and manual therapy program. In this specific case our goals originally worked to decrease the patient’s pain and determine the current level of function and ability of this patient. The patients MRI have shown us discs and boney segments with arthritic changes, but it was the overall muscle imbalance and weakness that caused the lack of spinal and sacral mobility. This led to a decrease in the patient’s ability to move in the correct biomechanical path and resulted in his pain. This was evident after we broke down the swing patterns of the body and tested out each of the body segments for balance, strength, stability and endurance. It was then that we realized how limited this patient was in terms of what he was requiring his body to do. The Selective Functional Movement Assessment (SFMA) was very helpful in breaking down each aspect of dysfunction in the swing and his active movements, so we could see which aspect of the movement was limited and if it was structural or muscular. As stated in the Nourbakhsh study of the relationship between “mechanical factors and incidence of low back pain,” they concluded that muscle weakness and decreased muscle endurance was associated strongly with low back pain and that the actual structural factors like lumbar lordosis, pelvic tilt and length of muscles of hips and abdomen did not associate with LBP [6]. This is what was seen in my case as well. The actual arthritic changes and disc herniation were not the specific cause of LBP but rather a result of poor mechanics that were created by weakness and tightness of muscles and capsules when the body tried to swing.

I feel that it is necessary to have a combination of both strengthening and manual work to lengthen the muscles. This combination allows for better body mechanics and decreases the risk of increased force on joints over years of play. Fitness and manual programs were created to strengthen, educate and lengthen all aspects of the body and mind. Golf is a full body sport that adds significant force through the spine and rotational torsion to multiple joints. This effort requires golfers to participate in a multi-discipline fitness and manual program in order to keep the joints and supporting tissues healthy.

References

1. Gluck GS, Bendo JA, Spivak JM. The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention. Spine J 2008;8(5):778-88.
2. McHardy A, Pollard H. Lower back pain in golfers: a review of the literature. J Chiropr Med 2005;4(3):135-43.
3. Rose G. The golfer's guide to lower back pain . Available from http://www.mytpi.com/articles/health/the golfer's guide to lower back pain/ Accessed on: July 27,2017.
4. Rose G. Back to Golf: Important Considerations for Golfers Undergoing Rehab Following Back. Available from http://www.mytpi.com/articles/health/back_to_golf_important_considerations_for_golfers_undergoing_rehab_following_back_surgery/ Accessed on: July 27,2017.
5. Murray E, Birley E, Twycross-Lewis R, Morrissey D. The relationship between hip rotation range of movement and low back pain prevalence in amateur golfers: an observational study. Phys Ther Sport 2009;10(4):131-5.
6. Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther.2002;32(9):447-60.