COHF 003: Professional golfer presents with sharp localized lower back pain.
In todays episode we discuss a case with a young, successful professional golfer presents with sharp, localized, lower back pain. His pain is along the left iliac crest approximately 4 cm from the mid-vertebral line. Pain began gradually as diffuse stiffness two weeks prior for no specific reason. Stiffness became more of a dull pain over the ensuing 10 days and was more noticeable while hitting golf balls..
Examination: Lumbar: F(60), E(30), RLF(30), LLF(30), RR(30), LR(30), with mild pain in the left lower back felt with RLF and LLF. Palpation of the left T10/11, T11/12 costovertebral joints was tender relative to the right and left quadratus lumborum.
Orthopedic: Positive Kemp’s, Yeoman’s, Milgram’s and Bechterew’s tests for left lower back pain. Braggard’s, Gaenslen’s, straight-leg raise and Mennell’s tests were negative. Standing upright and leaning his torso right, then left, was positive bilaterally for left lower back pain.
Neurological: Unremarkable with sensory and motor evaluation of the lower extremities.
Manual muscle testing: Left hip extensors +4/+5 relative to right (evident after five repetitions with 3-second hold each).
Selective Functional Movement Assessment:
- Pelvic tilt test: dysfunctional, no pain with pelvic flexion
- Pelvic rotation test: dysfunctional, painful – left (pain in low back, left groin)
- Single-leg rotation: dysfunctional, painful (left hip with ER and IR)
- Single-leg forward bend: dysfunctional, painful (left)
- Single hip extension: dysfunctional, no pain
- Prone active hip extension: dysfunctional, no pain
- Modified Thomas’ test: dysfunctional, no pain (iliopsoas)
- Lumbar extension: dysfunctional, painful (left)
Let’s Hear From The Council!
I would think they most likely have a reflex motor pattern issue concerning gait which is going to be a threshold issue during the strike pattern. Looking at things from a central to a peripheral basis. Want to check cerebellum, proximal joints, vestibular system and why it isn’t coordinating correctly with the muscular system. Will be prescribing movements such as rolling patterns, crawling exercises, all trying to fire up the intrinsic patterns, constantly monitoring the pain levels through out. Movements based on the central nervous system findings are going to be important to rehabing this.
Jeff talks about how golf is an overuse sport. Practice makes permanent. He would want to look at the kinematic sequencing. Each part of the body should be rotating relevantly to each other body part. If one is happening faster or earlier than the other, it is firing out of sequence. How is the rotary stability. Are they able to stay stable through the rotation. Try working on retro swinging to strengthen the opposite side of the spine. Shoes and foot mechanics are important for kinematic sequencing, along with breathing during the activity.
Stephen would want to check the history of injuries as well as the foot wear pattern to get a quick indication on the basic mechanics. 99% of the time the place that sore is not the primary problem. Check the muscle strength bilaterally. Check the fundamental movements as well as going through regression of movements. Is there hip rotations during squat and gait. Use a stretch cage to repeat those movements from her daily activities. Begin with some bio feed back and force plates to have the patient to improve their technique.
Dr. Brandon Brock
Dr. Brandon starts from a top down approach with a postural analysis. Checks the vestibular pathways, checking their limits of stability to determine which systems are involved. This will allow us to see what muscles are compensating due to where the body inappropriately thinks it is. Would check the ocular system, can they fixate or not? Eyes, paraspinals and vestibular systems to ensure they are all responding in sync. Would incorporate brain exercises along with whole body rotational exercises to get these systems firing in the same pattern. Would also validate there is no inflammatory diseases adding to this problem.
Dr. Emily Splichal
The strike pattern would be indicated with the information that the pain is increased during slower speeds. Pelvic floor testing would be good to see if it is engaging. If it is not activating appropriately then glute function is greatly compromised. This could indicate why the hip has pain. Would start the reprogramming with deep core stability, then build on that glute function. After that core to foot sequencing would be a progression before moving back into full running. Check the symmetry of the feet for navicular drop or calcaneal eversion.
What other activities is she performing. Many athletes change sports during different seasons. Also past injuries that may have inflamed this issue. In many runners the glutes are going to be a major issue, and something that needs to be checked. The IT Bands are going to be an area to check for asymmetric dysfunction that would be effecting the gait and biomechanics. The suprior tib-fibula need to be moving properly. If there is any IT Band dysfunction or restriction in the Tibula/fibula it is going to alter gait and cause these types of problems. Working through the hypertonicity and adhesions with some soft tissue work, thus restoring the function back to where it needs to be. Obviously depends how soon it is after the race, as to what we can do at that moment.
Let’s Here The COHF Summary from the President of the Council.
Dr. Mark Wade
Checking compensation from previous issues, looking at temperatures during training. 3D motion capture would be great for a transverse plane view. Strike patterns, gait movement, symmetry. Checking breathing for proper function and muscular compensation affecting this. Check the entire kinetic chain with muscle strength tests, and looking at functional movements. Top down approaches are good using posture analysis. Are there any limits in stability and how does it connect to the ocular system. Reactivate the core structure, using some glute activation as the primary focus. Bring the patient slowly back into activity. Can incorporate stretching and specific movements incorporating the spine and full body. Myofascial work can be utilized as needed as long as we aren’t inflaming the musculature. Want to reset peripherally where possibly, but continue to re-assessing. Clam exercises focus primary attention into the glute.
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Dr. Mark Wade: Council President, Posture Expert, & Global Health Leader, bringing insight together with the council on health, wellness, physical rehabilitation, neurology and exercise fitness strategies for health care professionals.