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Golf and low back pain - Part 1
By: Dr. Kerrie Evans (profile)
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This article focuses on three of my favourite low back exercises for golfers.

Fig.1

Low back pain can be an extremely frustrating injury which can not only affect your performance but will make playing a far less enjoyable experience. While we are really only just beginning to understand the complex relationship between the physical aspects of the golfer and the golf swing, research has shown that optimising your fitness can help prevent and manage low back pain episodes. This article focuses on three of my favourite low back exercises for golfers. Obviously, these are only a very small part of a much larger picture (hence the Part 1 in the title of the article!) but will start to introduce some concepts you may or may not be familiar with.

Fig.2

First, some background. Low back pain in golfers – is it really all that common? Unfortunately, low back pain is frequently reported by both male and female amateur and professional golfers. The stats vary a little depending on the type of study conducted, but, for example, one study found that 55% of professional golfers had experienced low back pain that was significant enough for them to miss at least one tour event or to play at an unsatisfactory level. This obviously represents an enormous problem for pro golfers.

Fig.3

Low back pain is also common amongst senior golfers and may be related to how often senior golfers play. Interestingly, one recent study found that 42% of senior golfers reported that their back pain was directly related to playing golf. That is, it isn’t just due to “old age”!

Fig.4

Young golfers are not immune either. In a study we conducted with young elite Australian golfers, over half (57%) experienced at least one episode of low back pain during a 12 month period and 36% of them felt that their back pain significantly affected their golf. Their average age was only 24 years! It is probably important at this point to put low back pain and golf into perspective - about 85% of the Western population will have an episode of low back pain at some point in their life, and for around 80% of those people, the low back pain will recur. So, for some golfers, the low back pain they experience isn’t directly related to playing golf, but for the majority of golfers I work with, being able to play golf is certainly their motivation for getting better.

Fig.5

Proposed causes This article won’t focus on the proposed causes of low back pain in golfers but suffice to say a number of factors have been suggested including:  Repetitive asymmetrical nature of the golf swing  Repetitive play and practice (overuse)  Changes associated with age (eg hip mobility)  Environmental factors  Swing changes  Ill-fitting equipment  Poor warm-up routines (check out the archived article from May 2008 about the importance of warming up!)  Poor physical conditioning.

Fig.6

Physical conditioning is a broad term which encompasses a golfer’s flexibility, muscle strength and endurance, balance and even cardiovascular fitness. The following exercises address a couple of these aspects of physical fitness. 1. Trunk muscle performance As a physiotherapist, I have been interested in the relationship between the biomechanics of the golf swing, the physical attributes of a golfer, and injury. One of the areas we have been researching is the relationship between the trunk muscles, particularly the abdominals, quadratus lumborum (Figure 1), and the trunk extensors, (specifically the erector spinae, gluteals and hamstrings), and low back pain in golfers. The trunk muscles and golf The trunk muscles play a very important role in the golf swing. They assist in producing and controlling the rotation of the trunk and pelvis. Strong contraction of the gluteals, particularly on the right hand side, extend the right hip during the downswing. Together with the hamstrings, gluteal muscle activation supports the pelvis and lower body throughout the swing, providing a stable base which allows the golfer to transfer their body weight during the swing. Another very important function of the trunk muscles is to protect the “passive structures” (e.g. the joints, ligaments and intervertebral discs) of the lower back during the powerful and rapid swing action. Trunk muscle endurance Given the important role of the trunk muscles in the swing, optimising trunk muscle peformance is a very crucial part of any golfer’s exercise program. One aspect of trunk muscle performance we measure in the clinic is “trunk muscle endurance”, which, put simply, is the ability of the trunk muscles to maintain a contraction over time. In the clinic, we assess trunk muscle endurance using tests such as those pictured in Figures 2, 3 and 4. What we are really testing is the person’s ability to maintain a position which challenges specific trunk muscles. For example, the side bridge endurance test specifically challenges quadratus lumborum as well as the lateral abdominal muscles. The Biering-Sorensen test challenges the trunk extensor muscles and the Ito test challenges the trunk flexors which includes the abdominal muscles. Before we go on, if you have lower back pain I would NOT recommend performing any of these tests until you seek advice from your health professional. And as always, stop if you experience any pain. Of these tests, the one I most frequently employ with the golfers I work with, both in testing and training, is the side bridge endurance test. This is because this position minimises the loading on the lower back and can be modified to suit most people (see Figure 5). It is also one of my favourites because a study we conducted suggested that, for young elite golfers, those whose holding time on their non-dominant side was BETTER than their holding time on the dominant side were more likely to experience lower back pain. That is, test yourself and if you don’t score about the same on both sides (allow a ±10 second difference) you should consider peforming this test as an exercise! Your holding time will be affected by your age, your body length and your weight but, as a rough guide, if you are aged between 18 and 35 years of age you should be able to hold this position for at least 95 seconds. If you score less than this, this exercise may be important to include in your exercise program. Typically, we don’t suggest peforming a maximal effort every time you do this exericse. A good place to start would be to halve your maximum score and peform as many repetitions as you are able. That is, if you scored 40 seconds, perform a 20 second hold followed by a 5 second rest and perform as many repetitions you can. Then repeat on the other side. If you scored under 30 seconds, start out using the modified position as shown in Figure 5 but use the same formula as above. Obviously, these are fairly basic guides - speak to your health professional or strength and conditioning coach for a more specific exercise program that will suit your goals. 2. Lower back extension exercises There are many very effective stretches for your lower back, although working out which ones are appropriate for you is the tricky part. Again, seek advice of a good health professional who understands golf. As a general rule, if your back is aggravated by walking, the following exericse may not be appropriate for you. Many of our day to day postures involve “flexion”, or forward bend, of the lower back. Sitting, sweeping, bending over to pick something up all typically involve low back flexion. During golf, you also spend considerable time in flexed postures – note the position of the golfer’s lower back in his putting posture in Figure 6! One of the most common stretches I ask golfers to do is a lower back extension exercise which really takes the lower back into the opposite direction to flexion. Extension exercises help take the load off the posterior part of the intervertebral discs, improves nutrition to the discs and can help improve the mobility of the joints in your lower back. You can perform this exercise lying down when you are at home or in standing when you are at the course.

Fig.7

For the lying extension exercise, lie on your stomach and place your hands near your shoulders. Start by coming up onto elbows. Ensure your hips stay on the floor and let your lower back “sag”. Stay in this position for 3 to 5 seconds and repeat up to 10 times. As your flexibility improves, come up onto your palms as is shown in Figure 7 and you can increase the time you are in this position. For the standing extension exercise, place your hands on the very low part of your back and slowly lean backwards. Hold this position for 3 to 5 seconds and repeat up to 10 times. This is a great exercise to do before you practice or play as well as during the round while you are waiting your turn to hit.

Fig.8

3. Hip flexor stretch The hip flexors also play a very important part in the golf swing. The hip flexors affect the position and the movement of the pelvis which then affectsthe position and the movement of your lower back. A number of swing faults can arise if your hip flexors are tight (e.g. poor posture at set-up, difficulty maintaining spine angle, reduced turn). Also, one of our earlier studies found that golfers with tight hip flexors were more likely to report that low back pain affected their ability to play well. The exercise shown in Figure 8 is also an important to one to do after you have performed the side bridge endurance exercises. This is because, when you place your arm over your head, you stretch the lateral trunk muscles which have worked really hard during the side bridge endruance exercise, possibly increasing the likelihood of them becoming tight. Start by kneeling on one knee (use a pillow if you need to). Make sure you keep your pelvis or bottom ‘rolled under’ and your lower back in a neutral position. Gently squeeze your gluteal muscles. You should feel a stretch in the front of your hip and/or thigh. Now, while maintaining that position, take your arm over the top of your head to feel a stretch in the side of your trunk. Maintain this position for at least 60 seconds. This is another great exercise to perform before practising or playing. Remember… Low back pain is extremely common amongst golfers and will affect your performance. With respect to low back pain and golf, all aspects of physical conditioning are important. This article has focused on only three exercises important for helping you optimise your physical fitness for golf. Look out for the next few articles from Ben Langdon which will discuss more ideas on how to improve your fitness for golf! Biering-Sørensen, F. (1984). Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 9(2), 106-119. Evans, K., Refshauge, K. M., Adams, R. A., & Aliprandi, L. A. (2005). Predictors of low back pain in young elite golfers: A preliminary study. Physical Therapy in Sport, 6(3), 122-130. Gosheger, G., Liem, D., Ludwig, K., Greshake, O., & Winkelmann, W. (2003). Injuries and overuse syndromes in golf. American Journal of Sports Medicine, 31(3), 438-443. Grimshaw, P., Giles, A., Tong, R., & Grimmer, K. (2002). Lower back and elbow injuries in golf. Sports Medicine, 32(10), 655-666. McGill, S. M., Childs, A., & Liebenson, C. (1999). Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Archives of Physical Medicine and Rehabilitation, 80(8), 941-944. McHardy, A., & Pollard, H. (2005b). Muscle activity during the golf swing. British Journal of Sports Medicine, 39(11), 799-804. Palmer, J. L., Young, S. D., Fox, E., Lindsay, D. M., & Vandervoort, A. A. (2003). Senior recreational golfers: a survey of musculoskeletal conditions, playing characteristics, and warm-up patterns. Physiotherapy Canada, 55(2), 79-85. Sugaya, H., Tsuchiya, A., Moriya, H., Morgan, D. A., & Banks, S. A. (1999). Low back injury in elite and professional golfers: an epidemiologic and radiographic study. In: M. R. Farrally, & A. J. Cochran (Eds.), Science and Golf III: Proceedings of the World Scientific Congress of Golf; 1998 Jul 20-24; St. Andrews. Champaign (IL): Human Kinetics, 1999: 83-91.

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