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Central low back pain

Central low back pain: The golfer who faked it

The stance may look good, but that doesn’t mean it is good. Scott Smith explains

John consulted me after experiencing his first episode of central low back pain. A keen amateur golfer, he played twice a week and practised most days for up to two hours. He did not, however, do any gym work or other exercise that would safeguard his all-round fitness and physiological balance so that he could play and practise as often as he fancied. John was also spending up to an hour and a half a day driving back and forth to his sedentary job.

In his youth John played a great deal of hockey, so he already had very developed quadriceps. When I looked at him in side profile, he exhibited what I call ‘office worker’s bum’: completely flat, with wasted gluteal muscles. Figure 1 (right) shows John’s postural typology with associated muscular patterns.

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John had taken lessons from a good golf professional and had worked on his posture in his set-up position. He achieved a good tall position, but not by extending through his thoracic spine (Figure 2, above,shows the correct spinal posture with a neutral lumbar spine). Instead he would over-extend his lumbar spine, arching his lower back. He was unable to achieve the movement through his thoracic region because it was so stiff from his time in the car and office.

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John was getting pain because in his diligent efforts to achieve good posture for his set-up, he had learned to recruit the wrong muscles to help stabilise his pelvis. This is similar to a weight-lifter who over-extends his lumbar spine when squatting, particularly in the decline segment of the squat.

Having already placed his spine in an extended (arched) position before he even moved, he could only increase the extension as he swung the golf club. He was unable to use his gluteal muscles to control the powerful rotational wind-up and release of the swing. He had trained himself to rely on his iliotibial band and lumbar erector spinae for muscular control.

In the golf swing, as in normal life, when you turn to the right you anteriorly rotate the left side of your pelvis and posteriorly rotate the right side. This allows your gluteal muscle to work on the posteriorly rotated side to absorb the weight transfer. And when you twist to the left, the same pattern occurs on the opposite side.

This is the most important element of the golf swing because it is the moment when most torque or twisting power is produced. The left side of the pelvis should be in posterior rotation and using the powerful gluteal muscle to resist the hit.

Golf coaches talk about correct sequencing or optimal timing of body parts in the swing. One of the most important parts is the turning or unwinding of the thoracic spine against a stable lead leg. This allows the gluteal muscle to absorb this force and not to transfer it to the spinal joints or muscles. Many less good players tend to drive their legs towards the target and do not use their abdominal muscles to rotate the spine around a stable leg.

I have two tests that I particularly like to use when assessing leg stability:

Single-leg stance with thoracic rotation

The client stands on one leg with the knee bent 20 degrees and their hands across their chest. They then rotate their chest to the left and right, trying to keep the lower limb relatively still.

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Possible compensations are:

* internal rotation of the femur

* pelvic drop on the opposite side

* side bending away from the stance leg

* overuse of the lumbar erector spinae and loss of gluteal contraction on the stance leg.

Side push against a wall, keeping the pelvis level

The client should push hard into the wall with the right knee but keep a gap between the hip and the wall (Figure 3, left). They should also try to turn the stance leg knee outwards. This creates a strong posterior gluteus medius contraction.

Possible compensations are:

* taking the leg too high up the wall so that the TFL can be recruited instead of the gluteal muscle

* over extending through the lumbar spine

* not being able to keep a gap between the wall and the pushing hip

* not keeping a level pelvis.

As well as a useful assessment test for gluteal weakness this is also a great exercise for any athlete who needs good single-leg strength. Hold the knee press for 30 seconds, then release. Repeat until fatigued, or for up to six repetitions. Change legs.

John’s treatment centred on improving his control of a neutral pelvic position, halfway between anterior and posterior pelvic tilt. I did a lot of trigger point releases of his psoas muscles, which allowed him to regain his lost range of hip and lumbar extension.

Luckily for John, his wife was a personal trainer, so we set about devising a programme of gluteal activation and strength exercises combined with thoracic rotation mobility drills. John also had to stretch his hip flexors (see Figure 4, below opposite) in the kneeling position by activating his gluteal muscles and rotating away from that side.

Conclusion

Despite John’s attention to the need for good posture in trying to improve his golf swing, he’d only succeeded in giving himself a very sore back. He was satisfied that he had to improve the strength of his stability muscles to control his extension and rotation, in order to enable him to play and practise to the level that he desired.

Posture can be deceptive. It may look right but the athlete has got there by the wrong means, usually because they have failed to understand the need for both good muscular control and also adequate flexibility.
 

Central low back pain