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Physical Therapy in Sport 6 (2005) 97102


Case study

A physiotherapy perspective on improving swing technique

in a professional golfer: a case study
Lynn Booth*
English Ladies Golf Association, Edgbaston Golf Club, Church Road, Birmingham B15 3TB, UK
Received 15 July 2004; revised 24 January 2005; accepted 30 January 2005

Providing information regarding the use of physiotherapy or related musculoskeletal conditioning to improve a sporting technique requires
experience of the sport in question, and knowledge of relevant research evidence and functional anatomy and their application to the sport.
Physiotherapists and other rehabilitation providers working with athletes must also ensure that they are working to the specific requirements
of the athlete and coach.
This case study outlines the effect of physiotherapy intervention over a 2-year period on the swing of a professional golfer. The essential
components required to produce a good result when treating sports injuries are highlighted. Such components include a detailed discussion
between the golfer, coach, and physiotherapist, the use of digital performance analysis, and the application of relevant musculoskeletal
profiling. Taking this approach provides a platform on which to devise an appropriate exercise intervention.
q 2005 Elsevier Ltd. All rights reserved.
Keywords: Golf; Musculoskeletal profiling; Sports injuries; Sports skills

1. Introduction
After 7 years experience of working with regional,
national, junior, and adult elite amateur golfers, I was
approached by a Professional Golf Association (PGA)
coach to provide an opinion on whether any aspect of
physiotherapy or related musculoskeletal conditioning
could improve the swing technique of a 30-year-old female
professional golfer.
The golfer, a naturally right-handed player who played
with right-handed clubs, played on the Womens European
Tour and frequently received physiotherapy treatment and
massage, mainly for the upper limbs and cervico-thoracic
spine, from physiotherapists working on the Tour and in her
local region. Due to the constant travelling to competitions,
however, the golfer was seldom at home long enough for
underlying causes of injury to be identified and adequately
* Tel.: C44 7770 236 226.
E-mail address: physiolynn@aol.com.

1466-853X/$ - see front matter q 2005 Elsevier Ltd. All rights reserved.

The golfer and her coach had decided that the priority
during the winter (non-competitive) training season would
be to modify her swing, in particular to develop a better
swing plane. Observing the golfer work with the coach,
followed by a musculoskeletal profiling session, highlighted
several areas that might benefit from physiotherapy
intervention. In general, these were a kyphotic thoracic
posture, reduced thoracic mobility, reduced stability and
control of scapulothoracic and lumbopelvic regions, and
weak lateral rotator cuff and abdominal oblique muscles.
These areas of concern are detailed more specifically under
the assessment section of this paper. In order to fully
understand the relationship between the golf swing and
physiotherapeutic methods a brief review of relevant
literature follows.
2. Review of literature
Reviewing relevant papers on common golf injuries (e.g.
Batt, 1992, 1993; Brendecke, 1990; Burden, Grimshaw, &
Wallace, 1998; Burdorf, van der Steenhovenm, & TrompKlaren, 1996; McCarroll, Rettig, & Shelbourne, 1990;
Metz, 1999; Nissinen et al., 2000; Seaman, 1998; Theriault


L. Booth / Physical Therapy in Sport 6 (2005) 97102

& Lachance, 1998) helped to define the areas that should be

considered during the physiotherapy musculoskeletal
Batt (1993) and Pink, Jobe, and Perry (1990) described
the mechanics of the golf swing as requiring rapid
glenohumeral movement through a large range of movement, necessitating an intact and functioning rotator cuff
firing in synchrony to provide a coordinated movement to
protect the glenohumeral complex. At the top of the
backswing the left arm of a right-handed golfer is in
maximal horizontal adduction and internal rotation.
Although shoulder elevation during the golf swing is not
usually greater than 908 in either shoulder until the end of
the swing, anterior joint line pain may be indicative of
impingement of the humeral head against the anterior
labrum (Jobe & Pink, 1996). Muscles responsible for
scapulae stabilisation have an important role in preventing
impingement (Regan, 1996). Batt (1992) reported that
shoulder injuries only accounted for 2% of the total injuries
of 193 amateur golfers. However, the golfers in Batts
(1992) report represented only a 42% response rate from one
golf club with an average age of 38.5 years and an average
handicap of 10.2. Studies on professional golfers have found
that the back, wrist, and shoulder were the most common
injury sites (McCarroll & Gioe, 1982), the injuries were
usually overuse in nature and right-handed golfers had more
frequent problems in the left upper limb (Theriault &
Lachance, 1998). Jobe and Pink (1996) reported only 98
new shoulder injuries (7.7%) in a 5-year period although
this was on the Seniors PGA Tour, where golfers were 50
years and older.
In a series of studies by one research group (Jobe,
Moynes, & Antonelli, 1986; Jobe, Perry, & Pink, 1989; Pink
et al., 1990), it was identified that the muscle work required
around the shoulder complex during the golf swing in
professional golfers was no different between men and
women in relation to the firing patterns of normal shoulder
musculature. A search of the literature has not identified any
studies detailing the muscular firing pattern in the shoulders
of injured golfers.
From extensive experience in working with elite
amateur golfers it is evident that, although acute
traumatic shoulder injuries do not commonly occur,
several elite (junior and adult) amateur golfers did
complain of chronic shoulder injuries. Jobe et al. (1986)
suggested that there might be more erratic firing of the
rotator cuff muscles in amateur golfers compared to
professional golfers. This does not reflect my own
experience that both amateur and professional golfers
complain of shoulder problems. It could be that Jobe
et al.s (1986) definition of amateur golfers actually
refers to recreational golfers rather than elite amateurs. As
refining the swing plane of the golf swing is a constant
coaching point for both amateur and professional golfers,
the importance of shoulder girdle and glenohumeral
control could not be overlooked.

Pink et al. (1990) suggested that as a golfer uses both sides

of the body in synchrony, right-handed golfers should
strengthen the left rotator cuff muscles to at least the levels
of the right shoulder. Exercise programmes for golfers should
include bilateral strengthening of the rotator cuff muscles to
provide a coordinated and protected movement during the
rapid, but not necessarily strenuous, arm activity. Biannual
musculoskeletal profiling of golfers by chartered physiotherapists working for the English Ladies Golf Association and the English Golf Union has shown that, in common
with other sports, the lateral rotator cuff muscles (infraspinatus and teres minor) tend to be weaker than the medial
rotator cuff (subscapularis) (Codine, Bernard, Pocholle,
Benaim, & Brun, 1997; Hall, Milligan, & Stewart, 1995).
An effective and efficient golf swing, that reduces the
propensity for injury, requires the spinehip angle to remain
constant, which in turn requires good trunk and hip rotation
(Booth & Forrest, 1999). Golf coaches use the term spine
hip angle to refer to a combination of spine/pelvis and
pelvis/thigh angles. Booth and Forrest (1999) suggested that
in order to enhance performance and reduce the likelihood
of low back pain, golfers must try to attain 908 trunk rotation
in both directions in sitting.
In common with other sports, golf coaches differ
amongst themselves on the technical aspects of the golf
swing, and it is important that physiotherapists and other
rehabilitation providers working with golfers and coaches
ensure that they are working to the coach and golfers
specific requirements.
The authors experience of musculoskeletal profiling of
elite amateur golfers had highlighted several common
themes, which were considered when assessing this
particular golfer. These themes included:
At the address position (the stationary position before the
golfer starts to move the club), the right hand is lower
than the left on the shaft of the club resulting in the right
shoulder being lower than the left. This habitual posture
results in some golfers demonstrating a scoliosis concave
to the right in standing, and many golfers show tightness
of the left upper trapezius and left levator scapulae with
associated lengthening of the right upper trapezius.
Despite being able to demonstrate good thoracic rotation
some golfers still tend to lose the spinehip angle or to turn
the whole body rather than just the trunk. The study by
Bechler, Jobe, Pink, Pery, and Ruwe (1995) highlighted the
muscle work in the hip and knee during the golf swing,
showing a sequential firing of muscles that generate power
from the lower limbs through the trunk to the upper limbs.
Whiteley (1999) suggested that higher handicap golfers,
in an effort to increase the ball-flight distance, try to
generate extra power from the muscles of the shoulders
and arms rather than the trunk. In the authors experience
the same applies to elite amateur golfers, thus placing
additional strain on the stabilisers of the scapulae and
glenohumeral joints. Mottram (1997) and Regan (1996)

L. Booth / Physical Therapy in Sport 6 (2005) 97102

highlighted the importance of static and dynamic

scapulae setting and discussed basic scapular stabilising
exercises that should allow golfers to control the golf
club during the swing.
A majority of golfers have poor endurance and strength in
the muscles of the lateral rotator cuff compared to the
medial rotator cuff muscle, particularly in the left shoulder.
Voight, Hardin, Blackburn, Tippett, and Canner (1996)
suggested that treatment protocols should emphasise
muscle endurance as shoulder proprioception (the ability
to reproduce a pre-established position) is diminished in
the presence of shoulder muscle fatigue. Scoville, Arciero,
Tayloy, and Stoneman (1997) suggested that the ratio of
eccentric lateral rotator cuff muscles to concentric medial
rotator cuff muscles in asymptomatic males was 1.08:1 and
1.05:1 in dominant and non-dominant shoulders, respectively. Their study, however, had several shortcomings; the
subjects had their upper body fixed by restraining straps,
the shoulders were only tested between 908 of lateral
rotation and 208 of medial rotation (not end-range for
medial rotation of the shoulder), and the isokinetic speed
was set at 908/s. Increasing the speed and extending the
lever by using a golf club would be expected to increase the
ratio. Ellenbecker (1996) demonstrated that isokinetic
testing of the medial and lateral rotators of the shoulder
showed significant differences in subjects with normal
grade strength measured using manual muscle testing.
However, the study used isokinetic speeds of 210 and
3008/s (far too slow to mimic a golf swing) and isometric
manual muscle testing.
In the absence of an objective test of rotator cuff strength
that can be used on the range rather than in a laboratory,
the author is still assessing muscle strength subjectively
using testing procedures suggested by Kelly, Kadrmas,
and Speer (1996), who used EMG (surface and indwelling) on the non-dominant shoulders of 11 normal subjects
to establish the optimal manual muscle test for the rotator
cuff muscles, although there is no mention of teres minor.
Although there is no research using randomised controlled trials to support the claim, many people
associated with golf (players, coaches, support staff)
suggest that improved lumbar/pelvic stability results in
improvement in ball-flight distance.
To reduce the strain on the upper limbs (Whiteley, 1999),
and in line with the findings of Watkins, Uppal, Perry,
Pink, and Dinsay (1996), golfers require trunk rotator
strength in outer range.

3. Initial contact
3.1. Assessment
The golfers local physiotherapist had suggested that the
golfers posture was too kyphotic, that she had poor weight


transference, was over-rotating her upper thoracic spine to

achieve distance during a full swing, and hyperextending
her upper cervical spine to get her eyes over the ball when
putting. The golfers posture and abdominal control had
subsequently benefited from Pilates intervention.
It was important to review the golfers swing with the
PGA coach using high-resolution digital cameras and
electronic software. This allowed the swing action to be
evaluated in both sagittal and coronal planes and at normal
and slow speeds. Subsequent detailed discussion of the
swing dynamics and the physical demands being placed on
the golfer allowed interpretation of the coach and player
requirements, and provided a platform on which to devise
relevant musculoskeletal assessment and exercise
Digital analysis of the swing showed that the golfer did
not over-rotate the thoracic spine during the swing but
actually over-protracted the left scapula. This fault had
probably developed to compensate for a lack of right trunk
rotation whilst still attaining the correct position of the club
head at the top of the backswing, and could explain the
recurring pain in the left scapula and upper arm, which had
caused the golfer to seek treatment during the season.
Using information from the relevant literature and
previous experience, the musculoskeletal assessment was
carried out. Salient points from the assessment of the golfer

Established kyphotic thoracic posture

Sitting trunk rotation; rightZ758, leftZ708
Reduced scapulae stability and control; leftOright
Weak concentric lateral rotator cuff muscles compared to
concentric medial rotator cuff; left and right
Poor lumbar/pelvic stability
Very weak outer range abdominal oblique muscles; left
and right
Pain and stiffness on palpation of T5-7 centrally.

3.2. Treatment
A regime of exercises was developed to address the
issues found on assessment. In particular, emphasis was
placed on the importance of improving trunk rotation
(Booth & Forrest, 1999), lumbar/pelvic control, and
scapulae stability and control (Moseley, Jobe, Pink, Perry,
& Tibone, 1992). Moseley et al. (1992) used EMG analysis
on nine healthy subjects with no shoulder pathology to
evaluate exercises in their ability to strengthen the scapular
muscles. For this golfer, the exercises suggested by Moseley
et al. (1992) were modified to avoid glenohumeral flexion
above 908 to reduce the risk of impingement of the humeral
head against the anterior labrum. The range of shoulder
flexion was slowly increased as the concentric lateral rotator
cuff strength improved. A resistance cord was also used to
strengthen the lateral rotator cuff muscles, in order to
develop the posterior biased shoulder described by Davies


L. Booth / Physical Therapy in Sport 6 (2005) 97102

and Dickoff-Hoffman (1993). Although golf is an open

kinetic chain exercise for the shoulder joint, both open and
closed kinetic chain exercises were used to help develop
dynamic stabilisation of the scapulae and glenohumeral
joints based on the suggestions by Wilk, Arrigo, and
Andrews (1996). As well, the progression of exercises
developed by Sahrmann (2002) was used to introduce
transversus abdominis into the golf swing to enhance the
golfers spinal stability and control.
Within six weeks of starting the exercise regime, the
golfer was able to incorporate some muscle control at
address position, and was aware of the need to continue to
work on the programme in order to improve muscular
control during the swing.

4. Two years later

After a further two seasons on the European Tour, the
player requested another assessment prior to commencing
her winter training programme. She was still working on
swing modifications and had experienced chronic injury
problems with her right shoulder during the previous season.
According to the player, an ultrasound scan had shown
inflammation (but no tear) of the biceps tendon and an
orthopaedic surgeon had injected the shoulder (specific site
not known) three months previously with initial relief.
After resting for three weeks she had played on the Tour
although did not recommence any upper body conditioning
work. The golfer had then been provided with a series of
shoulder exercises, including core exercises and resistance
cord work. After performing the exercises for one week the
golfer started to complain of pain in the right biceps tendon
and muscle, but nevertheless started a weights programme
including chest press, upright rows, shoulder abduction, and
lat pull downs. Local treatment (ultrasound, interferential)
had failed to resolve the right shoulder and upper arm pain
and four days prior to the assessment the golfer had stopped
playing after 10 holes due to pain around the insertion of
deltoid. Importantly, the golfer admitted that once the
competitive season had started, she had neglected the
exercise regime developed 2 years previously.
4.1. Assessment
A thorough assessment as again carried out. Salient
points from this assessment included:
Kyphotic upper thoracic spine with poking chinin her
general and golf posture
Good lumbar/pelvic control
Tightness in left upper trapezius muscle
Lengthening of right upper trapezius muscle
Sitting trunk rotation; rightZleftZ858
No abnormalities were detected in the cervical spine
No weakness of upper arm muscles

Reduced scapulae stability and control; rightOleft

Medial rotation of the right shoulderZ308. This was
measured from the neutral position for rotation (i.e. lying
supine, with 908 glenohumeral abduction, elbow flexed
to 908, and the forearm vertical) (Herrington, 1998).
Medial rotation of left shoulderZ508
Very weak posterior rotator cuff muscles in eccentric
outer range; rightOleft. This would be required to
control the glenohumeral joint as the range of shoulder
medial rotation improved.
It became apparent that the golfer was trying too hard to
correct her scapulae posture and was using the larger phasic
muscles of the upper back rather than the postural control
muscles of the scapulaethe substitution strategies discussed by Mottram (1997). However, Mottram (1997) also
suggested that with increasing loads (long limb lever) the
scapulae stabilisers must work above 30% of their
maximum voluntary contraction, although no evidence is
provided. The resistance cord work for the right shoulder
had been forcing the shoulder beyond its physiological
range of medial rotation. This could have an effect on
anteroposterior translation of the humeral head (Branch,
Avilla, London, & Hutton, 1999; Davies & DickoffHoffman, 1993; Kamkar, Irrgang, & Whitney, 1993),
although Branch et al.s (1999) study, which demonstrated
the relationship between the length of the posterior capsule
and humeral translation during medial rotation, was
undertaken on cadavers (i.e. without muscular control).
4.2. Treatment
Using video analysis, and together with the coach, the
necessity to improve scapulae stability, general and golfing
posture, the range of right shoulder medial rotation, and the
eccentric strength of the posterior rotator cuff muscles was
stressed to the golfer. Slow motion video also highlighted
over-contraction of the right upper fibres of trapezius at the
top of the backswing, which changed the direction of the
swing planefor this reason it was decided not to include
strengthening exercises for the right upper trapezius in the
exercise programme.
The lack of consistent improvement over the previous six
months and the golfers realisation that her game was being
compromised meant that she was more amenable to
committing to a relevant exercise programme. The golfers
rehabilitation was modified. The recent weights and
resistance cord work were stopped and the following
exercises were commenced:
Mobility exercises for
B Posterior capsule of the right shoulder (Branch et al.,
B Medial rotation of the right shoulder in 908 abduction
Active stretching of left upper trapezius and levator

L. Booth / Physical Therapy in Sport 6 (2005) 97102

Scapulae control and setting, avoiding any secondary

muscle contraction, initially in prone lying progressing to
Eccentric posterior rotator cuff strengthening, using
resistance cord in painfree range in supine lying with
shoulder abducted to 908.
The glenohumeral medial rotation stretching technique
suggested by Johansen, Callis, Potts, and Shall (1995) for
baseball pitchers was not used, as the method requires an
outside force to apply pressure to the scapulae in prone
lying. In order to develop compliance it was decided that all
the golfers exercises should be self-managed.
A lot of time was spent on the range with the golfer and
her coach practising improved posture at the address
position and during the swing. As one would expect, the
golfer was able to maintain a good posture at the address
position quite quickly, but was unable to maintain this as
soon as she moved the golf club. The golfer found it easier
to improve scapulae control when she combined this with
her ability to maintain lumbar/pelvic control using a submaximal contraction of transversus abdominis.
One month later, the golfer had committed well to the
exercise programme and reported only slight muscular
aching in the right upper arm. Medial rotation of the right
shoulder in 908 abduction had improved to 458. The exercise
regime was modified again to improve the eccentric strength
of the posterior rotator cuff muscles throughout the painfree
range and to commence plyometric (stretch-shortening)
exercises in middle range (Davies & Dickoff-Hoffman,
1993; Wilk et al., 1993).
The golfer, coach, and physiotherapist worked constantly
on improving spinal posture, shoulder girdle stability and
control throughout the swing, as well as the necessary swing
modifications. It may be that the improved muscular control
and endurance influenced the kinaesthetic receptors and
helped the golfer to make subtle adjustments in her golf
swing (Furness & Wellington, 1997; Voight et al., 1996),
although Voight et al.s study focused on asymptomatic
shoulders and was unable to detect if the subjects could
perceive the threshold of passive movement.
Once glenohumeral and scapulae control was maintained
on the range under practice conditions, where all three
participants (golfer, coach and physiotherapist) could refer
to video analysis when necessary, the physiotherapist
walked nine holes with the golfer and coach observing,
discussing, and where necessary modifying the golfers
posture, shoulder girdle stability, and control under more
realistic golfing conditions.

5. Conclusion
The golfer has resumed competition on the European
Tour, has had no reported recurrence of the shoulder
problems, and has performed well during tournaments.


This case-study highlights the essential components

required to produce a good result when treating sports
injuries. Theses components include:

Commitment of the golfer/athlete

Interest and involvement of the coach
Use of performance analysis equipment
Knowledge of functional anatomy and its application to a
particular sport
5. Ability of support staff to apply their knowledge to
particular facets of the sport and revise their opinions in
light of on-going findings.

This case study was written as part of the authors
submission to the British Olympic Associations (BOA)
Physiotherapy Register.

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