Improving Golf Swing Kinematics in a 78-Year-Old Golfer with Lower Back Pain: A Case Report

Introduction

Golf is one of the most popular sports in the world. Over 6 million Europeans and 26 million Americans play at least one round of golf annually [1]. Due to the complexity of the golf swing, poor form can lead to an ineffective swing, poor golf performance, and possible injuries [2].

The golf swing includes a simultaneous series of complex movement patterns throughout the human body. Four distinct phases can be identified: the setup, backswing, down-swing, and follow-through [3]. The main characteristic identified when analyzing the golf swing is the heavy reliance on torsional loads throughout the body to generate the force required to hit a golf ball [4]. A typical golf swing has simultaneous opposite upper and lower body rotational movements creating a torsional force in the spine [1]. The kinematic sequence between backswing and downswing in the effective golf swing reverses the initial drawback. Efficient rotational movements are essential to generate high club head speeds and ultimately increase ball speed and shot distance play [5].

This torsional movement results in significant loading throughout the spine and extremities, and with increased age, this might be challenging to achieve optimally [6.7]. Qureshi et al [8] demonstrated that about 45% of golfers report golf-related pain with aging. In an aging spine, normal processes such as osteoarthritis and stenosis will affect the spine’s functional mobility, negatively affecting the golf swing if degenerative changes occur. Not only will rotation and the extension motion decrease, but so will the lateral flexion of the trail side of the golfer. During the backswing, the golfer generates as much potential energy as possible for the spine and scapulothoracic muscles to be released on the downswing. To do this effectively, the golfer must be able to move the trunk from the pelvis independently [9].

A golfer’s ability to effectively complete the swing motion directly results from their combined physical limitations. The Titleist Performance Institute (TPI) identified a subset of 16 movements within a golfer’s swing that could lead to poor performance, dysfunction, and pain [10]. Based on these movements, the TPI has created a movement screening tool that fitness and health professionals can use to identify a golfer’s physical limitations that might lead to a poor golf swing [10]. Gulgin et al [10] demonstrated the overall usefulness of the TPI screening tool and how it correlates to the common swing faults in golfers. Additionally, Speariett and Armstrong [11] identified that the TPI Fitness Handicap score accurately predicts better performance, such as greater ball speed, clubhead speed, and peak pelvis rotation speed. It has been suggested that the TPI screening tool could be used as a functional assessment that would assist strength and conditioning professionals in addressing dysfunctional movement patterns specific to golf, overall aiding the improvement of the golfer’s performance [11]. However, there is a lack of research evidence to support this claim.

The most common physical limitations in the golfing population are the ability to perform the overhead deep squat, the toe touch movement, the single-leg balance, and the supine bridge [10]. These 4 movements are all incorporated into the TPI movement screen. In addition to these 4 physical limitations, Gulgin et al [10] identified the most common swing faults. These are early hip extension, loss of body posture, and a hip slide during the downswing phase. Based on the TPI movement screen, specific exercises are recommended by the TPI to address identified movement dysfunctions that will lead to an improved golf swing.

It has been shown that exercise programs, including resistance training, plyometrics, and flexibility exercises, offer positive benefits to the golfer with physical limitations [12–14]. Oranchuk et al [12] found that an 8-week strength and power training exercise program for collegiate golfers resulted in increased club head speed. Lephert et al [14] found that an 8-week golf-specific exercise program addressing strength, flexibility, and balance improves an amateur’s golf game. Despite this evidence for younger golfers, little is known about the benefit of the TDI movement screen and exercise program for the aging amateur golfer.

Analyzing the kinematic movement sequence in a golfer is an essential aspect of optimizing performance. Innovative technologies have made it possible to generate person-specific data to analyze all aspects of the golf swing [15]. An example is the Trackman (Vedbaek, Denmark) system. This technology provides a virtual golf simulation in which the golfer hits a golf ball into a screen with a driving range projected onto it. As the golfer hits the ball, the screen actively tracks the ball, showing the shot shape, distance, and roll-out of each shot in real-time. The Trackman software tracks distance, club speed, ball speed, and shot accuracy, among other data points [15]. To further analyze the golf swing itself, a motion capture system can be used to provide a detailed 3-D motion analysis. The K-Vest (K-Motion Interactives Inc, Scottsdale, AZ, USA) offers this option [16,17]. The K-Vest equipment is directly attached to the golfer and measures the golfer’s rotational movement in all 3 cardinal planes. This provides golfer-specific data on rotational speed, transition sequencing, and direction of the body in space [17].

To optimize performance, a combination of the TPI physical screen and subsequent targeted exercise program, 3-D bio-mechanical analysis of the kinematic sequence of the golf swing, and virtual shot analysis would be ideal. Therefore, the purpose of this case report was to describe improvements in a 78-year-old amateur golfer’s TPI composite score and golf swing kinematics when neuromuscular and mobility exercises, balance training, and muscle stretching interventions were directly based on the TPI movement screen.

Case Report

PATIENT HISTORY AND SYSTEMS REVIEW:

The patient was a 78-year-old man who played golf at the amateur level, on average, thrice weekly. He recently retired and started spending more time playing golf. He reported having intermittent low back pain for 10 years. No sudden onset or trauma related to this back pain was reported. His lower back pain was occasionally exacerbated by lifting heavy objects and “tweaking” his back. These occurrences had subsided, and a dull, persistent pain remained in the lower back. The patient reported that there had been no incidences of radiating pain or any other neurological symptoms. He reported that the pain was worse in the morning, and it usually took him 30 min to feel better after getting up to move around. The back pain lessened in the forward bend position and when sleeping in the fetal position. In addition to his lower back pain, the patient had chronic scoliosis with convexity of the curve in the left upper thoracic spine. He reported that his lower back pain did not limit his daily activities. He could participate in daily household chores, play golf and pickleball, and exercise moderately, including 2-mile walks outside or aqua therapy in his pool. Other than his spine-related challenges, the patient reported an inguinal hernia, dyslipidemia, and systemic arterial hypertension. The patient felt his golf swing had become “lousy”, and he lost drive distance. Therefore, his goal was 2-fold. One was to reduce golf-related pain and discomfort, and the other was to improve his swing and driving distance by 20 yards.

SYSTEMS REVIEW:

Table 1 shows the results from the patient’s systems review. After screening for red flags, no significant impairments were noted other than deficits in his balance. He was on various medications, including 2 statins for cholesterol, a diuretic to manage blood pressure, aspirin, and vitamin D.

INITIAL CLINICAL IMPRESSION:

The patient’s primary dysfunction was insidious low back pain. After ruling out potential red flags, differential diagnoses considered were lumbar facet joint dysfunction, spinal stenosis, mobility deficits, and movement coordination impairments. The patient was appropriate for further evaluation. One challenging aspect of the patient’s presentation was the presence of an inguinal hernia that was scheduled for operation 10 days after the initial consultation and measures. The hernia was reduced surgically, and our physical therapy sessions commenced 2 weeks later, to allow adequate healing time.

EXAMINATION:

All tests and measures were completed by a licensed physical therapist with TPI certification, and Table 2 summarizes the pre-intervention and post-intervention results. As part of the evaluation, the patient completed the TPI movement screen (Table 3). Tables 4 and 5 display golf-specific data points based on the Trackman and 3D K-Vest testing results.

Objective measures related to golf trunk rotation were assessed. This test was measured with a goniometer above the patient while sitting, holding his hands together at the level of his xiphoid process with fingers pointed out perpendicular to his trunk [18]. Trunk rotation to the right was 48°, and to the left was 60°. Golf requires adequate bilateral trunk rotation to perform an optimal golf swing. To create maximum clubhead speed, the modern golf swing requires full rotation during the backswing [10].

Shoulder rotation motion was measured using a goniometer while the patient was lying supine on a treatment table with his arm abducted to 90° and elbow flexed to 90°. It was previously demonstrated that shoulder internal and external rotation is essential for all aspects of the golf swing [19]. The patient’s bilateral internal rotation was limited. The shoulder internal rotation on the right was 58°, and the left was 46°. Shoulder external rotation was 85° bilaterally. Decreased shoulder rotation will negatively affect the golf swing. For instance, for a right-handed golfer, the left shoulder must undergo internal rotation during the backswing and quickly rotate into maximal external rotation during the swing and follow through [19]. The right shoulder will undergo rotations in the reverse.

The 90/90 test was used to measure the hamstring muscles’ length. During this test, the patient was supine with the hip and knee in 90° flexion. Knee extension was actively carried out and measured. This test has shown good reliability [20]. The right knee lacked 50° of extension, and the right 40°. This indicated significant deficits in hamstring flexibility.

The Oswestry disability index was used to demonstrate the patient’s disability related to his back pain. The Oswestry disability index has been deemed valid and reliable for measuring perceived disability in populations with low back pain [21]. The patient scored 2%, indicating “minimal” disability. The patient-specific functional scale (PSFS) was used to identify patient-specific functional limitations. The score is scaled from 0 to 10, with 0 being “unable to perform” and 10 being “able to perform an activity at the same level as before injury or problem”. Five golf-specific measures were used: bending to the ball, backswing, downswing, follow through, and a full round of golf. The PSFS is reliable (SEM=0.5, intraclass correlation=0.91) and responsive in chronic low back pain populations [22]. The minimal detectable change of the PSFS is between 1 and 2.5 points in patients with chronic low back pain [23]. Our patient scored a total of 47 points (Table 2).

The TPI level 1 movement screen was completed as part of the assessment (Table 3). This movement screen is used to identify any movement faults during the patient’s golf swing. The patient demonstrated limitations in bilateral pelvic and torso rotation. Both movements isolate either the pelvis or the torso and have it rotate independently of the other. When the patient repeated the motions with an external fixation via the physical therapist’s hands, bilateral motion was better for the hip and torso rotation. According to the TPI screen, this identifies that the golfer presents with a stability problem [10]. This stability problem will result in the typical swing fault characteristics recognized using the body-swing connection. These swing faults include loss of posture, reverse spine angle, flat shoulder plane, early extension, sway, and slide [10].

The patient displayed decreased balance control during the single-leg stance test. With his eyes closed, he could stand unsupported only for 5 s bilaterally. Single-leg balance is an essential aspect of the golf swing, for it happens at the top of the backswing and the finish of the follow-through. The golfer must shift their weight back to their trail leg during the back-swing and forward to their lead leg during the swing and subsequent follow-through. The golfer will create a swing fault without adequate balance on either of these legs.

The patient also showed limitations in touching his toes bilaterally when standing. The latissimus dorsi muscle length test in standing was positive bilaterally. The patient was limited in bilateral trunk rotation in sitting. Additionally, he cramped during a gluteal bridging exercise on his right side. He displayed normal mobility in the cervical spine. Wrist mobility was limited in extension, flexion, and radial deviation on the left.

The TPI movement screen provides an accumulative fitness handicap score indicating the level of dysfunction. A better performer is indicated when the number is closer to zero. Currently, no evidence supports the reliability and validity of the fitness handicap score of older golfers. The patients’ pre-intervention fitness handicap was 34.

Following the physical therapy evaluation and TPI physical screening, the patient was assessed for golf-specific data using the K-Vest and Trackman technologies. The primary measurements collected by the Trackman program were club speed, face angle, carry distance, and side accuracy. Although no normative data are known for older amateur golfers, Professional Golf Association tour averages are reported, as follows: club speed of 113 mph and carry distance of 275 yards [15]. Currently, normative averages are unavailable for face angle and side accuracy, potentially due to professional golfers purposefully varying these metrics for specific shot selection. Furthermore, club head speed is measured as the peak speed the club head reaches during a full swing through impact. Our patient had a club head speed of 75.9 mph. Face angle is the degree of the face of the club head during impact with the ball. The patient had a face angle of 6.6 (Table 4). The closest to 0° would be optimal. The patient had a carry distance of 152.3 yards and a side accuracy on the right of 40.5.

The K-Vest measures rotational velocities and static rotation at a specific point in a golf swing [16]. The body segments tracked are the pelvis, trunk, lead shoulder, and lead hand. The data points collected with the K-Vest include the swing sequence of the body segments, peak rotational velocities of these segments, and static rotation off-center for these points at different times in the golf swing. The patient demonstrated improper speed sequencing but higher peak speeds for 3 body segments (Table 5).

CLINICAL IMPRESSION:

The patient presented with lower back pain and declining golf performance. The initial clinical impression and differential diagnoses were joint dysfunction/hypomobility, movement coordination impairments, and mobility deficits. Following the objective examination and TPI movement screen, the most significant dysfunction was the diminished neuromuscular control around the trunk and pelvis. The patient’s lack of coordination in this area could have led to movement coordination impairments and likely contributed to his lower back pain during golf. Based on the patient assessment, physical therapy intervention was indicated, to regain neuromuscular control of the lower back and pelvis region. Additionally, the patient reported his desire to participate in physical therapy to alleviate his lower back pain during golf and improve his performance.

INTERVENTION:

The patient was seen for a total of 3 treatment sessions. Additionally, he was educated in a home exercise program to augment his treatment interventions. This home exercise program was completed daily for the entirety of the treatment time. The treatments were initiated following the patient’s abdominal hernia surgery. At 2 weeks after his hernia surgery, he was released by his surgeon to participate in golf. In weeks 3 and 10, the patient underwent the TDI motion screen and data capturing with the K-Vest and Trackman technologies to collect golf-specific data points. Weeks 3 through 10 following surgery included specific interventions (Table 6) to address his physical dysfunctions highlighted by the TPI movement screen. Each treatment session lasted about 45 min and involved one-on-one care focused on neuromuscular therapeutic exercise, balance training, and manual therapy. At each follow-up visit, the patient was re-assessed, and his augmenting home exercise program was reviewed. In this case, treatment interventions were chosen to treat flexibility, trunk, and pelvis neuromuscular control, hip and torso dissociation, decreased core activation and lumbar stabilization, and decreased dynamic and static balance control.

Each session (Table 6) began with neuromuscular control activities. Initially, the patient performed posterior pelvic tilts and progressed to pelvic clocks in subsequent sessions. These were included to initiate isolated pelvic control, which was found to be limited during the TPI movement screen. He also completed transverse abdominis activation, with subsequent progressions in follow-up treatments, including simultaneous leg movements. These exercises were chosen since it has been demonstrated that improved transverse abdominis control increases lumbar stability and reduces disability in individuals such as our patient [24–26]. Following this, the patient performed movements to help dissociate his pelvis and torso. Open books and lower trunk rotations were utilized to treat this dysfunction (Figures 1, 2). Next, the patient combined balance, rotation, and scapular muscle-strengthening activities.

These included physioball horizontal chops and physioball proprioceptive neuromuscular facilitation diagonal patterns D1 and D2, both with resistance (Figures 3, 4). This was followed by balance activities: single-leg stance on a foam pad and balance beam walks. These exercises were chosen to incorporate different aspects of balance that would support his golf game. The patient completed standing pelvic tilts and later progressed to alternating pelvic maneuvers to further facilitate neuromuscular control in that area. After the therapeutic exercises, the patient was placed on a treatment table and received passive manual stretching of his hamstrings, gluteus, and piriformis muscles.

Results

The outcome measures were completed at the initial assessment and the final third treatment session (Table 2). The patient completed the Oswestry disability index and patient-specific functional scale to capture pre-intervention and post-intervention functional measurements. There was no clinically meaningful change in the disability rating on the Oswestry disability index for pre-intervention or post-intervention measurements. However, according to the established minimal detectable change, the patient-specific functional scale did show a significant clinically meaningful change of 7 points, including a self-report of no disability when participating in a round of golf [22]. The patient demonstrated improvements in shoulder internal rotation. The right side improved from 58° to 75° and the left from 46° to 57°. Shoulder external rotation mobility on the right side increased from 76° to 85° and on the left from 80° to 85°. Hamstring length in the 90/90 test improved on the right side from 50° of knee flexion to 15°. The left side improved from 40° of knee flexion to 19°.

The post-intervention TPI physical screening showed improvements in several categories. Bilateral pelvic rotation improved to the normal category. Toe touch improved from the limited bilateral to the normal category. The 90/90 test improved to normal, as reported above. The bridge with leg extension test elicited a cramp initially and was rated as normal at post-intervention testing. The patient’s left wrist hinge limited radial deviation was resolved. However, he displayed limited left ulnar deviation at post-intervention testing. His initial limited wrist extension was rated as normal after his treatment interventions. Overall, the patient’s TPI fitness handicap improved from 34 to 12, reflecting a significant improvement. Despite these improvements, the outcomes for the torso rotation test and the seated trunk rotation remained unchanged. The cervical rotation test decreased in bilateral directions. The remaining tests on the TPI physical screening were rated as normal at pre- and post-intervention testing.

The K-Vest (Table 4) captured the golf-specific metrics, demonstrating improved club speed from 75.9 to 76.7 mph. The face angle decreased from 6.2° to 1.2°, and the carry increased from 152.3 to 156 yards. The patient’s score using the K-Vest swing Trackman technology demonstrated normalization of pelvic (from 7° to −1°) and trunk (from 6° to 12°) rotation (Table 5). Posture at address demonstrated normalization of trunk bend from 26o to 21o. Pelvis bend decreased by 3° but remained within the normative range. In relation to pelvic and trunk rotation, the pelvis top measure and the trunk top measure remained within the normative range. Although still not meeting the normative range, the pelvic impact score improved from 12° to 18°, and the trunk impact score did not change and remained 7°.

In summary, the patient improved his ability to move and golf-specific data points. The most significant positive golf-related measures obtained with the K-Vest equipment were a correction of peak speed sequencing, better pelvic and trunk posture at address, and better pelvic rotation at impact. Improvements were made in all categories collected with the Trackman shot analyzer. These categories were club head speed, face angle at impact, carry distance, and ball deviation from the center at the first bounce.

Discussion

LIMITATIONS:

There are limitations to this case report. The participant had hernia surgery 2 weeks after the initial evaluation and the first TDI movement screen. This surgery and his first 2 weeks of recovery time could have contributed to the patient’s pain resolution. However, this likely had little direct impact on his reported strength, range of motion, and balance improvement. One thing that was not controlled was his home exercise program. It is possible that the patient was not compliant and performed the exercises incorrectly, which could have affected outcomes. To minimize this, the patients’ ability to perform the home exercise program correctly was evaluated during each follow-up visit. Lastly, it must be noted that the patient did not perform a warm-up before completing the pre-and post-intervention TDI movement screens, nor was the time in the day for testing standardized. This may have affected testing outcomes [41].

Conclusions

This case report shows that improving a golfer’s TPI Fitness handicap score was directly related to measurable improvement in kinematic sequencing, as demonstrated by golf simulation and motion analysis in an aging golfer. Although, based on a case report, cause and effect cannot be established, it does appear that interventions in this case contributed to improved spinal rotation, decreased lower back pain, decreased self-reported disability, and improved golf swing kinematics and performance meeting the patient’s objectives. Therefore, aging adults, who report that golf provokes their back pain and whose focus is to improve their golf measurables, might benefit from a TPI movement screen and subsequent targeted neuromuscular reeducation and muscle stretching exercises in their treatment. Future research should evaluate the reliability of the TPI movement screen for the aging population as a predictor for injury and determine if it can also serve as a predictor for overall functional improvement in the aging golfer. There is a need to demonstrate the correlation between dys-functions identified in the TPI movement screen and the exercise interventions suggested by the TPI. Additionally, research should validate the TPI fitness handicap score and its correlation with the golfer’s kinematic sequencing during the golf swing.