Is it really Carpal Tunnel Syndrome?

Many computer workers complain of wrist pain from typing excessively. Is that pain Carpal Tunnel or is it possible something else? Unfortunately, many cases of wrist and/or forearm pain are automatically diagnosed as Carpal Tunnel Syndrome (CTS) without truly examining all possible causes of the pain. Not to say that CTS is not a common reality amongst many computer workers and those who work with their hands. However, CTS must be distinguished from Pronator Teres Syndrome for a positive resolution to occur. Both syndromes cause similar pain, but must be treated differently to achieve the desired results.

                Pronator Teres Syndrome describes a condition where the Pronator Teres muscle  in the forearm becomes over-used and scar tissue, adhesions, or muscular restrictions entrap the Median Nerve, causing forearm, wrist and hand symptoms similar to CTS. This nerve  runs between the two heads of the Pronator Teres muscle and may become entrapped.  When your forearms are in the typing position and performing key strokes, you are constantly activating the forearm flexors and pronator teres, which leads to overuse strain of those muscles and the possible nerve entrapment

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                Decreased sensation over the pad of the thumb (Thenar eminence) distinguishes pronator syndrome from CTS because the sensory branch of the median nerve that innervates the thenar eminence does not pass through the Carpal Tunnel. This is the key finding to look for when evaluating someone who has suspected CTS. Unfortunately, when the pain is misdiagnosed as CTS, the incorrect treatment protocols are rendered and no results are achieved. Even worse, the next step is Carpal Tunnel surgery and if it really isn’t CTS, then the surgery often fails.

 

The good news is that both conditions, if correctly diagnosed, can be treated with conservative techniques such as A.R.T® or Graston Technique®. If you are having hand/wrist/forearm symptoms, make sure to get it correctly evaluated and treated before the condition worsens.

Don’t Let Back Pain Get to You!

About 80% of Americans suffer debilitating low back pain at some point in their life. This fact is staggering, yet it doesn’t have to be this common. The key to staying out of this group of low back pain sufferers comes down to one word: Prevention.  If I had to choose one common problem amongst all low back pain sufferers it would be bad low back position during common activities such as brushing your teeth, bending over, picking up a small child, exercising and sitting.

The lumbar spine, which is the lower part of the spine, is meant to have a natural curve to it that displaces the forces of gravity, weight, etc evenly and minimally. When this natural curve is straightened or reduced, the forces on the discs, muscles, and ligaments of the low back are significantly increased. For example, sitting without maintaining the natural curve increases the forces on those structures by 30-40%!

To prevent low back pain you must learn to perform all activities with a natural curve. The best way to train yourself to instinctively do this is to do the hip hinge drill. Stand tall with a normal curve in the low back with a stick placed from your head down to your buttocks. Next, with a mirror to your side, bend over at the hips and not the low back. You will notice that the space between your low back and stick will be maintained. If you bend at the low back, the lumbar spine will touch the stick. Work on this until it becomes a natural movement and use this posture during all activities to prevent low back pain.

Chiropractic and Corporate Wellness

As you walk into the new Tyco headquarters in Boca Raton, FL you find yourself on “Main Street” with multiple store front signs such as a salon, Starbucks, technology store and eat well cafeteria. Amongst these stores you will also find a chiropractic office, massage therapy center, fitness center and primary care physicians. Once you realize you aren’t in a mall or a medical plaza, and are actually in a company headquarters, you become extremely impressed. It also becomes apparent that Tyco has made a concerted effort to improve the wellness and performance of their employees and is bucking the trend of most major corporations. This is a complete 180 from the old thought processes of how to incentivize the work force, and its truly remarkable. 

Recently, our practice was fortunate enough to be asked to run the Chiropractic Care out of this corporation. When we were approached with this opportunity, I was extremely impressed they thought of Chiropractic as an integral part of this program and excited to be a part of such a company movement. Being an A.R.T. Corporate Solutions certified practitioner through Active Release Technique® I have had some experience on a small scale in other corporations, but this was going to be a much larger undertaking. Where would we start?

First, we wanted to come up with a program that includes evaluation and corrective strategies for workstation related pain syndromes, overall chiropractic wellness, and family care. Since all immediate family members of Tyco employees can receive chiropractic services at the facility, this will be an integral part of our patient base. Secondly, we wanted to educate all employees on ergonomics, work station stretches/exercises, and prevention of over-use strain at the workplace. In our experience, optimal management of desk-related pain is chiropractic, soft tissue manual therapy, ergonomic advice and postural correction through exercise and awareness. Prevention of pain and injuries should be the number one goal of any corporate wellness program, so implementing the above prior to pain is paramount. 

In our practice we have treated many sports injuries, traumatic injuries and auto accidents utilizing chiropractic, rehab, Active Release Tecnique® and Graston Technique®. However, it seems that our most common patient these days is the computer/desk worker who sits for a living. As well, large corporations are seeing extremely high worker’s compensation costs due to these types of work related injuries. To quantify this, we will implement a record keeping system to compare the work comp costs prior to and after our program implementation. Our goal is to provide wellness for the employees and reduced costs to the employer. Since we have considerable experience in treating and preventing desk-related pain syndromes in our office, we have high expectations for our program at Tyco. All of what Tyco has assembled will come together to provide effective and convenient health solutions for both parties. 

If you are a computer or desk worker and are suffering from pain related to this, or want to prevent the occurrence of such pain please contact us for your own personalized treatment and prevention plan.

Poor Posture and Chiropractic Rehab

I found an interesting article written by Dr. Craig Liebenson, one of foremost Chiropractic authorities on rehabilitation of the spine. This article touched on poor posture as it relates to the Thoracic and Cervical spine and how it can generate from the Thoracic spine due to excessive sitting and slouching.

The first part of the article discusses the biomechanics of the Thoracic spine and sitting. It gets a little wordy but the point can be understood by anyone who sits a lot or has poor posture.

 
Biomechanical Underpinnings and Kinesiopathology

Figure 1: Forward head posture - upper-crossed syndrome.

A = correct; B = incorrect.

“The thoracic spine represents a critical, yet underappreciated spinal region.¹⁰ Of all structures, the thoracic spine is one of the most vulnerable in modern lifestyles. In the fetal posture, the entire spine is kyphotic. We are hard-wired to achieve a stable, upright posture by 4 years of age,³ yet due to television, soft couches, chairs, desks, computers, etc., the thoracic spine slips back into greater kyphosis. The result: straightening of the lower cervical lordosis with compensatory C0-C1 hyperextension, as the eyes must peer horizontally. In the lumbar spine, we find poor control of the natural lordosis with resultant disc vulnerability during activities of daily living, such as sitting, bending, twist, lifting, etc.

Having a stiff upper-thoracic spine also decreases our ability to activate the deep neck flexors and even the abdominals. With freely moveable vertebrae in this junctional area, we are able to achieve balance between the extensors and deep neck flexors, which ironically, originate in the mid- to upper-thoracic region.³“

Figure 2: Internally rotated arms.

“We know that with cervical rotation, we should appreciate motion all the way down to T4. Typically, patients with this restriction do not lose much active range of motion. It has been demonstrated that a significant association exists between decreased mobility of the thoracic spine and the presence of patient-reported complaints associated with neck pain.^78-9 In a controlled study, this treatment was determined effective by itself.⁴“ Cleland showed that in select patients, thoracic spine manipulation provided a successful treatment for patients with neck pain. Thoracic spine mobilization or manipulation acted as a component of a multi-modal intervention demonstrated to be effective for the treatment of patients with shoulder impingement syndromes.

After addressing the biomechanics Dr. Liebenson gives some great rationale for Chiropractic treatment and corrective exercises. In our office the combination is vital to ridding the patient of the symptoms and correcting the dysfunction. Here is a brief description of the Assessment Protocols the he recommends.

Assessment Protocols

“The masters of manual therapy are able to marry what they find with their hands through palpation with what they see with their eyes through movement analysis or functional screening. With finely tuned dynamic palpation skills, the physician is able to palpate joint restriction, joint hypermobility and soft-tissue pathology. As Karel Lewit once said, "The human hand is the greatest therapeutic tool that has [been] or ever will be invented." The purpose of functional assessment is to identify a patient's functional or performance deficits and capabilities. Structural problems, such as disc herniations or arthritis are noted but not over-emphasized to the patient.”

Chiropractic’s New Role in the Golf Community: Part 4

Treating the Injured Golfer

 

The previous installments of this series have for the most part focused on the healthy golfer and how you can play an instrumental roll in helping their game. In this article, the injured golfer will be the subject, and will be your main role in the golfing community. It goes without saying that Chiropractic treatment is great for treating golf related injuries, but the goal of this article is to discuss common golf related injuries and detail how to evaluate and treat golfers in a way that will maximize your results and increase your referrals from local teaching professionals.

In dealing with golf related injuries the majority will be due to repetitive strain or over-use in nature, as is the case with many injuries or pain syndromes seen in our clinics. In the golfer these injuries are most commonly produced by poor body mechanics, poor swing mechanics, excessive practice, poor nutrition, and improper club fitting. In Chiropractic, we pride ourselves in finding and treating the underlying cause of the pain, not just covering up or only ridding our patients of pain. As we all know, pain is the last to come and the first to go and comes back if the dysfunction is not treated and corrected. With that being said, you would be missing the boat if you only evaluated and treated the poor body mechanics, when the cause of their pain or injury may be caused by improper swing mechanics or improper club fitting. Improper swing mechanics may be the root cause of their joint/muscle dysfunction and pain. For this reason, a full evaluation should include video analysis of the golf swing to determine if any swing faults are producing their pain. The video analysis should be performed when the golfer can swing normally without any pain. I challenge you to take any golf certifications that teach this information because it is an extremely valuable tool in truly evaluating the cause of injury in golfers.  If this knowledge is not currently possessed, setting up a referral system to local teaching professionals for swing and equipment analysis is recommended. 

The most common repetitive strain injury sites in golf occur to the low back, lead elbow, lead shoulder, lead wrist and left ankle in order of prevalence. These injuries consist of sprain/strains, tendonitis/tendonosis, arthritis, disc injuries, and tears. Knowing what injuries occur to golfers is important, but knowing how poor swing mechanics causes those injuries is what will separate you clinically in the golf community. Below is a list of most common low back and elbow injuries and what swing faults cause them.

Swing Faults that Cause Low Back Injuries

Swing Faults are technique flaws and improper swing mechanics that place under stress on the body and negatively affect the golf swing.

S-Posture: Excessive lordosis in the lumbar spine during address and throughout the swing. This causes inhibition of the abdominals and glutes. This “Lower Crossed” presentation produces facet syndrome and myofascial pain.

Reverse Spine Angle: The golfer’s spine tilts towards the target at the top of the backswing. The golfer uses the erector spinae to go into extension on the back swing and causes excessive compressive and shear loads on the lumbar spine.

Early Extension: The golfer goes into rapid hip and spine extension during the downswing which causes the hips to move towards the golf ball. This movement shuts off the abdominals ability to stabilize the core.

Restricted Right Leg Follow-through: The golfer does not release his/her right side during the downswing and after impact. This forces a large deceleration torque in the low back and spine.

Reverse “C” Finish: Finishing in a full hyperextension position that puts excessive stress on the lower right facet joints

Swing Faults that Cause Elbow Injuries

Chicken Winging: The lead arm doesn’t fully extend into impact. This causes excessive lead arm extension forces and excessive trail arm flexion forces at the elbow.

Over-the-Top: The plane of the downswing is too steep. This causes the lead wrist to extend and the lead elbow to flex causing excessive loads to the forearm muscles.

Casting: Early release of the proper wrist angles prior to impact. This places excessive forces on the trail arm forearm flexors.

Dysfunctional Lower Body- The inability to optimally fire and utilize the hips and legs in the golf swing is the main cause of chicken winging, scooping, and over-the-top swing faults. The lack of power production from the lower body forces the upper body to over compensate and leads to over-use strain of the upper extremity. Also, the inability to separate the pelvis independently of the torso will cause early initiation of the upper body/upper extremity in the golf swing. This will produce an upper body dominant golf swing.

Chiropractic’s New Role in the Golf Community: Part 3

Program Design for the Golfer

In the previous installments of this series I have covered the basics of Chiropractic’s new role in the golf community and Golf Specific Functional Screening. Program design for the golfer is the next step in the process, following the thorough golf fitness evaluation. The golf fitness program can be coupled with manual therapy for quicker and more effective results, or if the golfer is suffering from nagging injuries. In this article, I will be covering program design for the healthy golfer whose goals are performance enhancement and injury prevention. In the next installment, I will discuss treatment options and protocols for golfers, and how to implement golf specific corrective exercises into your treatment plan.

As a chiropractor/golf fitness & injury specialist, your role can consist of performing the golf physical screening, treatment of injuries, and program design, but it should end there. You should then give your report of findings and/or program design to a golf specific fitness trainer to carry out the program. The trainer should be able to carry out your initial program and have the knowledge to recognize when to progress the golfer as his/her fitness level increases. You may choose to have a trainer on staff if you have a capable facility. The other option is to refer your golfers to a local trainer who is qualified. This will also help build a two-way referral network between you and the trainer for their other clients.

When designing a golf fitness program, Tables 1.1 and 1.2, and the golfer’s screening should be the template to build their program. Along with general golf specific exercises, the program should be designed to provide the golfer with proper ankle mobility (dorsiflexion), knee stability, hip mobility & stability, lumbar/core stability, thoracic mobility, scapular stability, and glenohumeral mobility. Notice the body’s alternating pattern of mobility and stability. This is important because if an area of the body is lacking its desired function, the area above or below will negatively compensate, which decreases performance and increases injury. For example, if a person lacks proper thoracic spine mobility, in particular extension and rotation, the lumbar spine and scapulo-thoracic joint will adapt by providing extra mobility, which is a dysfunctional compensation. This person will typically present with a rounded upper back and shoulders at address, lack of scapular stability, and lack of core stability and strength. The common mistake many corrective exercise programs make, is that it only includes scapular and core stability exercises, and that’s a good program. Most people don’t even take into consideration the importance of scapular stability in shoulder function. What your golf program should include along with the scapular and core training, is thoracic mobility exercises. This kinetic chain training should be utilized for all most people, especially athletes.

In some cases, the golfer will have a high level of fitness and the initial program will not include too many corrective exercises, so you can proceed with more advanced exercises and power training. However, most golfers, even high level golfers, will have physical limitations and the initial 2-3 months might be dedicated to cleaning up those findings and building a solid foundation to build upon. Advanced golf exercises, plyometrics, and power training should be reserved until the golfer demonstrates a solid fitness foundation. Too many sport specific training programs try to build power, speed, and coordination on an insufficient foundation, which is counterproductive and may even lead to pain or injury.

When designing a program for competitive golfers, your program needs to reflect which part of the season they are in. This periodization of their program will ensure peak performance during the most important time of the year. During the season, their skill training/playing will make-up about 70-80% and fitness 20-30% of their golf allotted time. Too much physical training will be counterproductive, so gear the workout to maintenance. During the off-season, they should be dedicating a lower portion of time to skills training to make room for a full golf fitness program. Finally, pre-season training, which lasts about 4-6 weeks, should be high skills training and a tapering of the intensity of the physical program.

Table 1.1

Table 1.2 Target Areas of the Body

Program Design Guidelines

• The ultimate goal of a golf fitness program is for Performance Enhancement & Injury Prevention.

• The Golf Fitness Assessment should be the foundation of the program design.

• The initial program should be a blend of exercises/stretches that correct physical limitations and general golf specific exercises, and should progress in difficulty as the golfer’s fitness level increases.

• Golf fitness is a combination of optimal balance, coordination, mobility and stability.

• The golfer should be trained for muscular strength, power, and endurance, not hypertrophy and cardiovascular endurance. Strength and power is optimally trained with low reps (1-8) and longer rest periods. Muscular endurance is trained with high reps (15-20) and short rest periods.

• A full General Fitness Assessment and Injury/Health history should be taken to rule out any contraindications to certain exercises.

• The program should include all of the Golf Fitness Training Goals (Table 1.1) and should target the Golf Specific Muscle Groups (Table 1.2).

• Advanced exercises and power training should not be implemented until a solid foundation has been achieved by the golfer.

• A pre-practice and pre-round warm up should be given. This warm up should consist of 6-8 dynamic stretches that takes 5-7 minutes to perform. All stretches should be designed to be performed without having to get on the ground.

• Program design should take into consideration if the golfer is in his/her preseason, midseason, or off-season.

• Factors when designing the program include the golfer’s fitness level, age, injury/pain history, goals, and facility/equipment available. 

Below is an example of a basic golf fitness program including screening findings along with corrective and golf specific exercises. If you have any questions regarding the exercises below or other exercises feel free to contact me.

The Chiropractors’ New Role in the Golf Community: Part 2

Golf-Specific Chiropractic Functional Screening

In part 1 of my golf and chiropractic series I discussed the basic principles of being the golf chiropractor in your area. Amongst other topics, I touched on the golf physical screening as the foundation for a golf fitness program. I will now expound on that concept as well as discuss using the screening for treatment purposes by detecting the root cause of the over-use injury. To properly utilize the golf specific screening, you must understand what physical limitations may produce certain swing faults.

As a Chiropractic Physician, the golf physical screening can serve many roles in your clinic and is a necessary tool when working with golfers. Being a chiropractor trained in golf fitness and injury prevention allows you to work with golfers in the following scenarios.

Scenario 1: You can perform a comprehensive head-to-toe screening for the purpose of developing a full golf fitness program to enhance the golfer’s overall performance. This scenario often requires a trainer on staff to work with the golfer. I will discuss this scenario in detail in part 3 of this series titled Program design for the golfer.

Scenario 2: A golf pro sends you a golfer who is limited in his ability to maintain his posture throughout the swing. As the golf biomechanics expert, you perform a concise screening to check for proper ankle dorsiflexion, hip mobility, ability to separate the upper body from the lower body, and adequate core stability to see what, if any, physical limitations are causing this swing fault. Your spot screening will then dictate what stretches or exercises you prescribe the golfer to clear up those limitations you found. The use of chiropractic adjustments and soft-tissue therapy will hasten the process of correction.

Scenario 3: An injured golfer comes to you seeking treatment for golfer’s elbow. The most effective evaluation would be to obtain a video analysis of the golf swing to see if the golfer is casting or swinging over-the-top, which would place excessive strain on the upper extremities, especially the elbow. It is recommended to first perform a full chiropractic examination and determine that the golfer is able to swing without significant pain. If this is the case, the next step would be to screen for the physical limitations that may cause this swing fault. Possible limitations may be lack of proper hip rotation on the downswing, lack of forearm and wrist strength and/or flexibility, and the above limitations that lead to loss of posture. When the golfer suffers from any of these physical limitations, he/she will be forced to swing over-the-top, swing with the arms excessively, and/or casting will be unavoidable due to the forearm and wrist issues.

After this detailed screening, you determine the golfer to be free of these limitations that cause golfer’s elbow. This shows that the swing fault is not due to a physical limitation, but rather a technique flaw. If you don’t have video analysis available you can opt to just physically screen the golfer for any physical limitations that are known to cause injury or a swing fault. However, I do recommend the use of video for a more thorough and revealing screening.

For this case your treatment plan should consist of conservative treatment of the elbow and referral to his or her golf pro for technique training to fix the swing faults mentioned. If the swing faults that cause the injury are not addressed the problem will persist or come back once the golfer resumes regular play.

Knowing when to perform the golf physical screening is obviously essential; however, the keys to the screening are knowing what areas of the golfer’s body to screen as well as how to screen them. There are many different ways to screen the same joint or muscles and it would be impractical to discuss each one in detail. So, whichever way you have learned will be sufficient as long as the test is effective, consistent, and tests for movement patterns. Movement quality is more important than basic muscle testing for strength. We need to know how these muscles would act during the golf swing. The following list is a comprehensive summary of what muscles and joints of the golfer should be tested and what they should be tested for.

Mobility/Flexibility

• Ankle Dorsiflexion

• Hip Internal/External rotation

• Adductors

• Quadriceps

• Hamstrings

• Hip Flexors

• Quadratus Lomborum

• Pectoralis Major

• Latissimus Dorsi

• Shoulder internal/external rot.

• Upper Trapezius/Levator Scap.

• Cervical Rotation

• Wrist mobility

Activation, Strength, Endurance And power

• Quadriceps strength & endurance

• Adductors strength

• Gluteus Medius activation

• Gluteus Maximus activation, strength and power

• Core Stability ( Abs, Quadratus Lomborum, Low back musculature)

• Mid Back (Rhomboids, Middle/Lower Trapezius)

• Rotator Cuff (especially subscapularis)

• Pectoralis Major strength, end., power

• Latissimus Dorsi strength, end., power

• Triceps/Grip Strength

The italicized muscles note the fact that these muscles need to be tested for strength as well as for flexibility. If one of these italicized muscles are excessively tight it will cause altered movement patterns as well as decrease the muscle ability for optimal power production. Flexibility and mobility of the muscles and joints allows the generation of elastic energy, and establishes a base for efficient power production. This is why a bodybuilder doesn’t hit a golf ball as far as an average size professional golfer.

In addition to the muscles and joints the golfer should be screened for golf posture, balance, torso rotation, coordination, and scapular stability. Golf posture is extremely important to evaluate since it in itself can be a predictor of over-use injury and/or swing faults. The two main golf postures that should concern you is the upper crossed syndrome and the lower crossed syndrome. Both limit range of motion in the golf swing, as well as place increase stress on the surrounding structures. The upper crossed golfer looks hunched over from the mid back to the neck at address, while the lower crossed golfer has a Hyperlordosis of the low back with the appearance of the buttocks sticking out. For example, an upper crossed syndrome golf posture limits the amount of shoulder external rotation in the back swing as well as cause over-use strain to the shoulder, neck, and mid scapular region. The lack of shoulder external rotation will inhibit the golfer’s ability to perform a full back swing.

The utilization of a golf specific screening in your clinic is essential if you want to excel in the golf community. Whether your screening is comprehensive for purposes of designing a full golf fitness routine or used as part of your treatment protocols for the golfer, it will separate you in the eyes of the golfer and local golf professionals. For any questions regarding how to screen a golfer for a particular muscle, joint or movement pattern email Dr. Christie at drkchristie@gmail.com

Chiropractic’s New Role in the Golf Community

In case you haven’t noticed the beautiful relationship between chiropractic, golf, and practicing in the sunny state of Florida, I am here to show you the endless possibilities that exist. In this 4-part series I will discuss how the chiropractor can attain both great results in working with golfers and become known as the golf doctor in his or her area. My goal of this series is to lay out the most effective way to evaluate, treat, and design programs for the golfer. I will begin by outlining what golf fitness and injury prevention entails and what knowledge you need to succeed in this field.

Let me preface this article by refuting a myth; you don’t have to be a golfer to specialize in the treatment, injury prevention, and fitness of golfers. However, knowing the biomechanics of golf and the human body is essential to understand what the golfer’s body is subject to during the golf swing and the possible causes of injury. This knowledge will also be critical when conversing with local golf professionals when you start to work with their clients.

The absolute foundation of any golf fitness program is the golf performance evaluation. This assessment is necessary to determine any physical limitations which will lead to swing faults and/or over-use injuries. The golf performance evaluation should consist of a video swing analysis and a golf physical screening to properly diagnose the golfer. The role of the video swing analysis is to visually see any swing faults or flaws that may produce miss hits, loss of power, or injury. Today, many golf performance enhancement certifications train you to diagnose from video, but, not to give technique training. Technique training is out of your scope and should be left to the golf professional. If you don’t feel comfortable with video analysis you can have the golf professional provide you with his or her assessment. However, it is important to know what physical limitations contribute to the swing faults identified.

The term swing fault describes any aspect of the swing that is not sound in its technique. These swing faults are caused by two issues; either a technique issue or a physical limitation. As stated previously, technique flaws are for the golf professional, whereas the physical limitations are for the golf doctor. For instance, the golfer with a flat shoulder plane during the backswing may not understand what a proper backswing should be, but during your evaluation you determine the golfer is lacking the necessary shoulder range-of-motion and/or chest and lat flexibility to perform a full and proper backswing. Can the golf pro alone fix this backswing? No, but with the help of the golf doctor who specializes in golf fitness and injury prevention, he can. The challenge of distinguishing swing fault from technique error is where the golf physical screen comes into the picture.

By following the video swing analysis with the physical screen, you can confirm the suspected physical limitations that may be producing the dreaded swing fault. I suggest a head to toe screening that tests the golfer’s core stability, flexibility, joint mobility/stability, balance & coordination, and muscular strength & endurance specific to golf. The screening will make the connection between swing fault and physical limitation by cross referencing your findings from the video analysis and the screening. The golf swing is full of these swing fault-physical limitation connections and differing between a technique flaw and a physical limitation is paramount in the success of the doctor and golfer. On top of that, you will make the golf pro look better due to the simple fact that after clearing up or lessening the physical limitations, the golfer will be able to execute what the pro is asking of him or her. When you consistently achieve these results you will see many referrals from golf professionals seeking to get their golfer in better “golf shape” or to clear up nagging injuries.

Now that you have uncovered the golfer’s weakest links, your next step in the process is to design a corrective exercise program based on his or her golf performance evaluation. The program’s initial goal is to clear up the issues deemed to be physical limitations as to improve performance and to prevent the injuries that these limitations cause. Strict adherence to these exercises will allow the golfer to turn his or her weak links into their strengths. Once the golfer has reached this point you can now develop a program that is more advanced and geared towards performance enhancement. If you were to build a program without clearing up the physical limitations, you most likely would be feeding their dysfunction. This dilemma could actually cause more swing faults and definitely increase the risk of over-use injury.

This process of evaluating a golfer described above should be for the relatively healthy golfer without acute injury. The basis for a golf fitness program can simply be for performance enhancement and injury prevention, or can be abbreviated to search for the root cause of an over-use injury. In this instance, I recommend treating the golfer’s acute injury conservatively with chiropractic care until the pain has subsided enough to allow normal movement. At this point it is time to perform the video swing analysis to look for any swing fault that could be causing the over-use strain to the given structure. With video in hand, next perform an abbreviated golf physical screening that pertains to the swing faults discovered. Your prescription to the golfer would then be to continue conservative treatment; address the physical limitations found in the abbreviated screening, and refer the golfer to golf professional to check his technique flaws that may be causing the pain syndrome.

This protocol for treating the golfer is not only comprehensive and effective; it will get the attention of the local golf community as to your expertise in the field. In the subsequent parts of this series I will describe in detail Golf specific functional testing, Program design for the golfer, and treating the injured golfer.

Preventing IT Band Syndrome

IT Band Syndrome is one of the most common causes of knee pain in runners. It is an overuse injury caused by repetitive friction of the iliotibial band across the Lateral Epicondyle (see image below). This syndrome presents as lateral (outside) knee pain due to tightness of the ITB and hip abductors. As a result of movement of the band during flexion and extension of the knee and hip, a tight band could be responsible for the inflammation at the knee or even the hip, or along the IT Band.

The main physical causes of this condition are:

• Tight IT Band.
• Altered foot function: Excessively flat feet cause the lower leg to internally rotate excessively, adding a stretch tension to the IT Band.
• Decreased Glute Medius/Maximus function.
• Overactive TFL muscle due to lack of Gluteus Medius function
• A weak or inactive Vastus Medials (VMO). This is the inside muscle group of the quadriceps and tends to become weak on people.
• Medial (inward) knee migration during walking/running.
• Leg length discrepancy.
• Tightness of hamstrings/Quads/Calves

Other non-biomechanical reasons for the condition can be improper running technique, worn-out or improper running shoes, hill running, canted running surfaces, and increasing mileage too fast. If you feel any of the non-biomechanical reasons may be an issue, please confer with your running store or coach.

1-Leg Stance Test for hip/foot/ankle instability      

Gluteus Medius Activation for hip stability

^{Hip instability causing knee inward migration This places excessive stretch on the IT Band}

^{Foam Rolling for IT Band}

From a physical standpoint, the best way to prevent IT Band Syndrome is to correct the causes by performing stretches and exercises to correct any of these above dysfunction. Stretching or foam rolling for the IT band, Hamstrings, Calves and Quads is necessary. Secondly, you need to be evaluated to determine if you have excessively flat arches or excessive pronation of the ankle. If you have flat feet, an orthotic may be beneficial. Lastly, strengthening of the hip stabilizers (glutes) and proprioception training of the ankle are recommended.

If you are, or in the future, suffer from IT Band Syndrome, conservative treatment usually does a great job of freeing you from your pain. In our practice we utilize Active Release Technique (www.activerelease.com), Graston Technique (www.grastontechnique.com) and Kinesio Taping along with other modalities to treat the pain and prevent it from coming back. I recommend you familiarize yourself with the above techniques if you are a runner; they are the top conservative treatment methods running related over-use injuries.

Preventing Low Back Pain

Low back pain is the most common pain syndrome in America today, and it is not limited to only the sedentary. Runners and many athletes suffer from this condition on a regular basis and there is usually a combination of physical causes and altered running or walking biomechanics that may be causing the condition.

The main physical causes of this condition are:

• Over-pronated or Supinated (high arch) feet
• Tight hip flexors
• Excessively flat or arched Lumbar Spine
• Joint restrictions in the thoracic spine or pelvic region
• Limited Hip range of motion/ Limited hip extension
• Weak Core Stability- Abdominals, Lumbar erectors and Deep Core
• Weak/Inactive Glutes
• Tight Hamstrings
• Altered Hip Extension Pattern- Discussed below

Hip Extension Firing Pattern

When extending the hip (leg pulling through and back) during running or walking, as in picture 3 below, the glutes should do most of the extension. The low back and hamstrings should be “helpers” during this movement. In many runners, this pattern gets altered due to weak glutes and overactive low back and hamstrings. When this happens, too much stress is placed on the low back and hamstrings. Tightness ensues in these two structures and this is two of the main reasons runners will suffer from low back pain.

Biomechanical Video Analysis

In the clinical setting we evaluate all runners walking and running for clues that may give us the understanding of how their injury is occurring. We don’t assess the video for running technique, but rather biomechanical faults that put excessive strain on certain structures that may be causing the runners pain. Below are a few examples of findings that can cause low back pain, amongst other injuries.

Unstable Foot/Ankle (pronated)

Hip Instability

Limited Hip Extension

Other non-physical reasons for the condition can be improper running technique, worn-out or improper running shoes, and increasing mileage too fast. If you feel any of the non-physical reasons may be an issue, please confer with your running store or coach to address them. Another huge problem in today’s society is sitting too much. Even as an active runner, sitting constitutes much of our day while at work and home. Research shows that sitting places 40% stress on the discs and muscles of our Lumbar spine and is the main cause of chronic low back pain.

From a physical standpoint, the best way to prevent low back pain is to obviously correct the causes by performing stretches and exercises to correct any of these above dysfunction. Strengthening for the Glute Max, Glute Medius, Foot/ankle and Core (See pictures below) is a must. Secondly, you need to be evaluated to determine if you have excessively tight hamstrings, flat or high arches and unstable ankles, altered curve to the lumbar spine (too flat or too arched), tight hip flexors and other muscular imbalances that places undue stress on the Lumbar spine.

Glute Bridges- Strengthens and activates the Glute Max, the main muscle group responsive for glute function and hip extension.

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Side Leg Lifts- Strengthens and activates the Glute Medius, the main muscle group in providing hip stability during one leg stance and running.

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Bird Dogs- Increases core stability and endurance to prevent weakness in the low back.

Bird Dogs

If you are, or in the future, suffer from Low Back Pain, conservative treatment usually does a great job of freeing you from your pain. In our practice we utilize Active Release Technique (www.activerelease.com), Graston Technique (www.grastontechnique.com) and KinesioTaping along with Chiropractic modalities to treat the pain and prevent it from coming back. I recommend you familiarize yourself with the above techniques if you are a runner; they are the top conservative treatment methods running related over-use injuries.

Preventing Plantar Fasciitis

Plantar Fasciitis is one of the most common causes of heel pain in runners. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, which runs across the bottom of your foot — connecting your heel bone to your toes. 

Plantar fasciitis causes stabbing pain that usually occurs with your very first steps in the morning. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing, getting up from a seated position, or running/waling. [1]

The main physical causes of this condition are:

• Tight calves will increase tension on the plantar fascia.
• Altered foot function: Excessively flat or high arches.
• Lack of big toe extension- Upward movement of the big toe.
• Tight hip flexors will reduce ability to use gluteals in ‘push off’ phase of stride, hence increasing the work load on the plantar fascia and calves. {2}
• Reduced gluteal and hamstring strength will again increase the demand on the calves and plantar fascia, predisposing to overload of these structures.{2}

Other non-biomechanical reasons for the condition can be improper running technique, worn-out or improper running shoes, and increasing mileage too fast. If you feel any of the non-biomechanical reasons may be an issue, please confer with your Friends In Training coaches to address them.

From a physical standpoint, the best way to prevent Plantar Fasciitis is to obviously correct the causes by performing stretches and exercises to correct any of these above dysfunction. Stretching for the Gastrocnemius (upper calf), Soleus (lower calf), hip flexors (See picture below), and the Plantar Fascia (See picture below). Secondly, you need to be evaluated to determine if you have excessively flat or excessively high arches. If you have flat feet, an orthotic may be beneficial. With high arches, manual therapy can help reduce the rigidity and tightness of the foot/arch. Lastly, strengthening of the glutes and hamstrings (along with hamstring flexibility) are vital to proper push-off mechanics during running.

If you are, or in the future, suffer from Plantar Fasciitis, conservative treatment usually does a great job of freeing you from your pain. In our practice we utilize Active Release Technique (www.activerelease.com), Graston Technique (www.grastontechnique.com) and KinesioTaping along with other modalities to treat the pain and prevent it from coming back. I recommend you familiarize yourself with the above techniques if you are a runner; they are the top conservative treatment methods running related over-use injuries.

Graston Technique for Treatment of Injuries

Graston Technique® utilizes patented stainless steel instruments, uniquely shaped, to treat different areas of the body. The weight and design of the various instruments allow clinicians to effectively treat deep tissue dysfunctions, while preventing the stress associated with manual therapy on their own extremities.

When the instruments contact the adhesions, the patient and clinician will notice a distinct feeling of going over a “speed bump” or gravel-like grittiness. Graston Technique breaks down and releases these “speed bumps” or scar tissue. Over time, this process generally will reduce or eliminate the adhered fibers, restoring function and eliminating the pain associated with it.

Injuries will be treated at the site of pain or scar tissue; however, clinicians will scan the surrounding areas, following the kinetic chain to find if there is an underlying cause of the injury. Often the clinician will treat the region in a position or movement that causes the pain or mimics the sports movement pattern. For example, a golfer who has lead shoulder pain at the top of the backswing and into the downswing may be treated in these positions and movements. Also, a key benefit to patients is they are able to engage in everyday activity or sport during treatment.

Active Release Technique for Golf Injuries

ART has been developed, refined, and patented by P. Michael Leahy, DC, CCSP. Dr. Leahy noticed that his patients' symptoms seemed to be related to changes in their soft tissue that could be felt by hand. By observing how muscles, fascia, tendons, ligaments and nerves responded to different types of work, Dr. Leahy was able to consistently resolve over 90% of his patients' problems. He now teaches and certifies health care providers all over the world to use ART.

Active Release Technique® (ART) is a patented, state of the art soft tissue system/movement based technique that treats problems with muscles, tendons, ligaments, fascia and nerves. Headaches, back pain, carpal tunnel syndrome, muscle strain, shoulder pain, sciatica, plantar fasciitis, knee problems, and golfer’s elbow are just a few of the many conditions that can be resolved quickly and permanently with ART. As the name implies, ART uses motion to fix the problem. Once the injury has been assessed, the provider uses hands on treatment and patient motion to “free up” the adhesion or restrictions within the muscles, tendons, fascia, etc. These conditions all have one important thing in common: they are often a result of overused muscles, Cumulative Injury.

Cumulative Injury Cycle

The Cumulative Injury Cycle (above) represents the process in which over-use injuries and pain occur. The process begins with Overwork, such as bodybuilding, sports and certain work requirements. This combined with a sedentary lifestyle or repetitive activities leads to Weak & Tight Muscles throughout the body. These weak and/or tight muscles lead to excessive Friction, Pressure and Tension to the local muscles, ligaments, tendons, and fascia. In turn, Decreased Circulation, Swelling and Hypoxia (lack of oxygen) to the area ensues. Due to this hypoxic state, formation of adhesions and/or scar tissue occurs to the area which decreases the function of the local structures. This becomes a vicious cycle that over time results in inflammation, pain and injury.

Implementation of ART to weak or tight muscles with the above mentioned restrictions is necessary for stretches or strengthening exercises to be more effective and in turn correct muscular imbalances. These muscular imbalances are the root cause to many over-use injury and pain syndromes.

Every ART session is actually a combination of examination and treatment. The ART provider uses his or her hands to evaluate the texture, tightness and movement of muscles, fascia, tendons, ligaments and nerves. Abnormal tissues are treated by combining precisely directed tension with very specific patient movements.

These treatment protocols - over 500 specific moves - are unique to ART. They allow providers to identify and correct the specific problems that are affecting each individual patient. ART is not a cookie-cutter approach.