Jus$n

Zych, PT, DPT

Brooks Orthopaedic Physical Therapy Resident
October 6, 2015

 Review clinical case of LBP developed from

frequent golf.
Iden$fy normal and abnormal forces on
lumbar spine during the golf swing.
Discuss role of structures in lumbar spine at
risk of injury due from golf .
Suggest exam ndings that can poten$ally
bias dierent structures in the lumbar spine.

 56 y/o Male Recrea$onal

golfer
Social Habits:

Currently smokes
>4 drinks per day

Physician referral:

LBP and return to golf

Oswestry (ODI): 18%

 Onset of concordant pain: November 2014

Previously had mild typical soreness a^er golf
Woke up day a^er golf and B LBP pain was intense
Con$nued playing, pain increased
Stopped golf completely for last 2-4 weeks
Intense morning pain
Unable to nish a full round due to pain

Travels 1-2 $mes a week with pain

PSFS: To return to golf without pain (7/10)

Loca$on

Bilateral
L pain more no$ceable than R

Descrip$on

Dull ache
Occasionally sore if move wrong

Aggrava$ng

Twis$ng, golf
Standing or sifng over 1 hour

Relieving
24 hour pahern

Stretching
Aleve
Pain worst rst thing in the morning
Felt more on the L side

Facet
Dysfunc$on
Sacroiliac
Joint
Dysfunc$on

Instability

Low Back
Pain
Stenosis

Disc
Pathology

 Observa$on:

Thoracic kyphosis, decreased lumbar lordosis

Lower Quarter Screen:

normal

MMT:

Hip Flex: L: 4/5 (concordant L LBP), R: 5/5

Motor Control:

Mul$dus Ac$va$on:

Absent contrac$on on L, Delayed ac$va$on on R

Transverse Abdominus Ac$va$on:

Impaired ac$va$on, unable to sustain contrac$on

Palpa$on:

B QL turgor (R>L)

Le#-sided Pain

Right-sided Pain

Ac2ve ROM

Flex: WNL
L lat ex: 25% limited

Ext: 50% limited

L Rota$on: 25% limited
R lat exion: 25% limited

Passive ROM

Ext: 50% limited

Ext: 50% limited

L rota$on: WNL

Resisted Tes2ng

L hip exion

L rota$on

Neurodynamic Tests:
(-) Slump Test B
(-) SLR and Well SLR B

 Joint Assessment:
Thoracic Findings:
Hypomobile throughout

General Lumbar ndings:
CPA painful centrally from T12-S1
CPA most painful at L3-5
R UPA painful at L3-5
No pain with L UPA
Increased mobility from L3-5

R L3-5 Facet Dysfunc$on

Painful Spring Tes$ng
L3-5 produced
unilateral R pain
Pain with extension, R
side bend, L rota$on

But concordant pain

was bilateral?
L LBP with:
AROM lumbar exion, L
lateral exion
Resisted iliopsoas
contrac$on
Subjec$ve report of pain
worst in morning

 Address:
Primary spine angle

Back Swing
Controlled separa$on of
upper thorax from lower
body

Downswing
Accelera$on, de-rota$on of
trunk from backswing

 Impact

Max R lateral exion

Fastest L rota$on moment
Decreased trunk exion

Follow-through

Large eccentric demand to

decelerate a^er impact
End in lumbar hyper-
extension, L rota$on,
R lateral ex

 Normal axis of rota$on:

Posterior-medial aspect of vertebral body

Excessive rota$on approximates contralateral

facet:
Shi^s axis of rota$on to approximated facet
Larger torsional force on intervertebral disc

 Func$on:
Shock absorber
Resist torsional forces
Increased load ahenua$on in exion

Abnormal axis of rota$on:

vertebral body shi^s more laterally
and posteriorly increasing lateral
shear and torsion on annulus.

Innerva$on?
Coppes et al. 1997

 Hysteresis
Tissue restores shape
and mechanical
proper$es at a slower
pace than which is was
deformed
Due to energy lost
during deforma$on

Fa$gue Failure
Repe$$ons happen
frequently enough that
$ssue does not have
$me to recover
Less stress needed for
$ssue failure

Exam Findings
Thoracic hypomobility

Impaired mul$di and

transverse abdominus ac$va$on

Biomechanical Abnormali$es
Impaired stabiliza$on of lumbar
spine

Lumbar facet approxima$on

shi^s axis of rota$on

Tissue Damage
Excessive shear forces to
annular bers

Annular tear due to repe$$ve

overload

 Unloaded spine results in low pressure within the

nucleus.
Ahracts water into the disc

First thing in morning, pressure inside the disc is

at its highest
Will decrease with load (compression will reduce
height of nucleus, expanding nucleus radiallypufng
pressure on annulus

Increased morning hydrosta$c pressure with

early loading to disc increases pressure on
annular tear

 Psoas Major
O: Transverse processes
of T12-L5 and IV discs
I: Lesser trochanter
Ac$on: Hip exion,
ipsilateral side bend

Le# Annular Tear

Right L3-5 Facet Dysfunc2on

Pain with:

Painful Spring Tes$ng L3-5

produced unilateral R pain
Pain with extension, R side
bend, L rota$on

AROM: ex, L SB
Resisted hip exion
Waking up in morning

Pa$ent Considera$ons:
R handed golfer experiences L rota$on from backswing -> follow-through

R facet approximates, L posterolateral mo$on of vertebral body
Repe$$ve MOI, 3x/week
Pain not present each swing, increased throughout round
Currently smokes

Poten2al Value:

Limita2ons:

Are there exam ndings

that can bias the annulus?

MRI gold standard for dx

Preven$on
Prognosis
Exercise Specicity

Biomechanical model
Psychosocial factors not
emphasized

No PT literature on clinical
u$lity of tests for dx annular
tears

So^ Tissue
Mobiliza$on

Improve
Thoracic
Mobility

Improve Motor
Control

Diagonal
Concentrics

Diagonal
Eccentrics (Golf
simula$on)

Modied
Rota$onal
Tension

Swings on
unbalanced
surfaces

Resisted Swings
for Power

Unrestricted
Return to Sport

Ac$vity Modica$on
Decrease frequency
Prac$ce swings
Club selec$on

Dynamic warm-up
Prognosis
Longer $ssue healing?
Facet and disc
Time for adequate dose
with exercise specicity

Updates on POC:
One setback a^er driving
range
Importance of pace of play

Now:
Golfs 1-2x/week
Able to nish rounds
without pain
Minimal pain in morning
No pain while travelling

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Cleland J, Koppenhaver S, Neher FH. Neher's Orthopaedic Clinical Examina$on, An
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Cole MH, Grimshaw PN. Electromyography of the trunk and abdominal muscles in
golfers with and without low back pain. J Sci Med Sport. 2008;11(2):174-81.
Coppes MH, Marani E, Thomeer RT, Groen GJ. Innerva$on of "painful" lumbar
discs. Spine. 1997;22(20):2342-9.
Drake RL, Vogl W, Mitchell AW et al. Gray's Anatomy for Students. Elsevier Brasil;
2010.
Gluck GS, Bendo JA, Spivak JM. The lumbar spine and low back pain in golf: a
literature review of swing biomechanics and injury preven$on. Spine J. 2008;8(5):
778-88.
Hosea TM, Gah CJ. Back pain in golf. Clin Sports Med. 1996;15(1):37-53.
Neumann DA. Kinesiology of the Musculoskeletal System, Founda$ons for
Rehabilita$on. Elsevier Health Sciences; 2013.
Panjabi MM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol.
2003;13(4):371-9.


Special thanks to:
Dr. Raine Osborne, PT, DPT, OCS, FAAOMPT
Dr. Laura Fitzgerald, PT, DPT, OCS, CSCS
Dr. Trent Harrison, PT, DPT, OCS, FAAOMPT
Dr. Michael Bourassa, PT, DPT, OCS, FAAOMPT