Case Study of a Golfer
Lost scholarship, lost interest, lost cause?
I was visited by X, a 17 year old boy who had recently lost his scholarship to a prestigious school in America because he was unable to compete in a golfing competition. He was feeling anxious and depressed that he might not be able to carry on with his passion. His playing had been limited the last six months because of upper thoracic pain specifically towards the medial part of his left scapula and he had virtually played no golf the last six weeks as the pain had become so unbearable. He reported a great deal of discomfort after playing that never really went away.
He had been seen by an orthopaedic consultant who took images and confirmed there was nothing structurally wrong. He’s also seen a physio (rubbed painful spot and made it worse) and a McTimony chiropractor (some manipulation around thorax and told him his pelvic floor was weak and to work on his core). He felt the chiropractor helps a bit but the issues came back within days.
Making the initial Pilates Therapy assessment for X
I always start with history (birth to now) and other than a current broken toe, nothing unusual revealed so we decided to stay away from the feet for now and got on with the screening (the therapy part). It was clear he was round shouldered with a kyphotic/lordotic posture and he was an apical breather (high in his chest) which goes with the pelvic floor dysfunction his chiropractor had pointed out. His pelvis rotated to the right (perhaps due to broken big toe); other hip, pelvis and spinal screens revealed nothing note worthy other than he slightly pronated his left foot and supinated his right (this went along with his right pelvic rotation). His ribs also rotated to right (not unusually for a golfer) and his cervical spine rotated left (eyes always find a way to face forward).
Deep dive shoulder screening and forgotten history
I guessed his rhomboids were probably weak (physio released them and it made things worse) so I went through the basic shoulder screens we teach our Pilates therapy students: biceps, coracobrachialis, pec minor, before moving onto screening his rotator cuff muscles. Both arms showed something going on with his biceps but what was really interesting was when I tried to screen his left arm we noticed he struggled to supinate his forearm which meant externally rotate the whole arm was difficult. Now he remembers an injury to his left thumb when he was seven that resulted in him being in a cast for several weeks. He also stated that he was left handed but played golf with his right. This was interesting so we looked further, he had lost grip between his little finger and thumb and external rotation of his rotator cuff was limited but his internal rotation was so great it looked like he was dislocating his shoulder. This made me screen him for hypermobility which he wasn’t so we carried on with the session.
Manual screening and manipulation of the forearm – and of course, the homework!
Us Pilates Therapists are hands on and are qualified to use manual therapy which we did on his forearm to enable him to be able to supinate his left arm. Like magic his shoulder fell back into place, hip grab came back and his rotator cuff screens improved. His homework was to continue to release his forearm with trigger pointing and to strengthen his supinators and infraspinatus using a band. He also was taught an MET to free up his right bicep and postural awareness to integrate the ‘new’ position for his shoulders. I also gave him a rotational exercise I call ‘side glides’ to help him find the optimal movement naturally.
Breathing and pelvic floor investigation
Next session we looked at his breathing. He did not present with a trauma or stress that might bring it on so we investigated his pelvic floor (that his chiropractor had picked up). We started with basic Pilates diaphragmatic breathing exercises, some basic pelvic floor recruitment exercises but it became clear very quickly that something was not right in this region. He reported it felt like it was burning massively and was uncomfortable so I chose to use some of my NKT skills and did some perturbation testing on him that showed he held himself up completely with his pelvic floor so it was not weak but dysfunctional and held. We gave him a ‘pelvic floor release’ and some breathing exercises. His perturbation tests improved hugely and all his discomfort went away. This is a lesson that the cause of dysfunction can be from muscles being over active or under active when strength muscle testing a muscle!
I sent him away with positional taping and homework for pelvic floor release, breathing and to continue with the arm homework from the previous session.
From thorax to gait – following up
I saw X two weeks later he was much better and the pain in his thorax had gone. He had played a few games of golf and had almost hit a hole in one on his first ball. He said he hit the ball further and couldn’t believe he could do this after all the time off he had had.
Now we would now concentrate on making him the best player he could be, continuing to work on his breathing and activation of TVA without over working his pelvic floor. We also looked at his gait and how his now healed toe might have affected his walking now it wasn’t so painful. It was clear he did not extend his hips or move through his feet well. I screened his foot with the Jack’s test, which showed little mobility in his big toes (why he could not move through his feet) which is why he had adopted a pattern of lifting his legs in front of him to walk (I had actually spotted this on day one but didn’t go there because of the broken little toe).
We took him through plantar /dorsi flexion with flexed toes on the wunda chair and this revealed that his fibula (same side as broken toe) was not moving. Restoring this movement greatly improved his big toe flexibility. His other leg was a different story, it was the lack of movement in his talus (perhaps a pattern he had developed from his golfing). Working on his talus and the movement in his other big toe greatly improved the mobility in both his feet and when I asked him to walk again he not only had a better stride but his torso rotated much more and his arms were swinging (before they only moved from the elbow hence the bicep tightness).
He felt so confident that he was off to America for a golfing competition the next week so we gave him mobility exercises for his feet with long stride walking after and to continue what he was already doing. Let’s hope his competition went well and we will continue to work together after the summer holidays