Injuries to the back are by far the most common in golfers, regardless of age. The causes for back pain vary, however, with amateurs getting injured from poor mechanics, pros getting injured from overuse, and Tiger Woods getting injured from…well, you can be the judge of that.
Whenever I am evaluating a golfer, injured or not, I always check hip rotation range of motion. Hip rotation, specifically hip internal rotation, is one of the main points of rotation in the golf swing (along with thoracic rotation), and is paramount for proper turn in the backswing and lower body action in the downswing to finish. Any reduction in hip internal rotation can be detrimental to golf performance, causing excessive lateral motion, loss of posture, and worst- not being able to bomb it off the tee as far as your buddy.
Lack of hip internal rotation can also spell problems for the lower back. A study published in Physical Therapy in Sport looked at hip rotation mobility in rotational athletes with and without lower back pain.1 Athletes with lower back pain had less overall hip rotation range of motion as well as asymmetry compared to those without lower back pain. In another study, Dr. Vad and his colleagues studied the relationship of the hip and back in professional golfers.2 A deficit in lead hip internal rotation (left hip of a right-handed golfer) was correlated with lower back pain in pro golfers. Using the concept of regional interdependence, this relationship between hip range of motion and back pain makes sense. The hip should have 30 + degrees of internal rotation (my golfers I prefer to have 45 degrees or more). Compared to the ~10 degrees of total lumbar rotation, the hip should have significantly more rotational forces going through it in the golf swing. However, what if hip mobility is reduced? The golfer is still trying to make a proper turn and hit the ball as far as possible. The body can’t get the necessary motion from the hip so it steals from an adjacent area, in this case the lumbar spine. But that lumbar spine isn’t really meant to rotate much, and if we continue to try and force additional rotation out of it eventually break down and pain can occur.
An obvious solution is therefore to 1) determine if there is indeed a hip rotation mobility limitation and 2) correct it to restore normal lumbo-pelvic mechanics. If there is a soft tissue limitation, we can use our various tools to improve mobility- manual techniques, dry needling, instrument-assisted soft tissue techniques, stretching, etc. If there is a joint capsule restriction we can perform mobilizations and/or manipulations to increase motion. But what if intra-articular pathology exists, such as a cam or pincer deformity and/or hip labral tear, which is limiting range of motion? In such cases, pain often co-exists at the hip (almost always anterolateral hip pain) especially during activities involving the extremes of hip flexion and/or rotation. Femoroacetabular impingement (FAI)- which results from body abutment of the femoral head/neck on the acetabulum- is common in rotational sports such as golf, and several notable players- Greg Norman, Brandt Snedeker- have undergone arthroscopic surgery to correct the bony deformities and associated labral and cartilage damage. Outcomes after arthroscopy for FAI are overall positive, and a recent case series of 20 professional golfers undergoing the procedure showed that all were able to return to golf at the same skill level and, in fact, their mean driving distance actually improved post-operatively.3
While certainly promising, the surgical outcomes for professional athletes can be better than the average recreational athlete. The recreational golfer likely has work or school demands, and due to time or insurance benefits, may not be able to undergo professional rehabilitation daily like many pro golfers. Additionally, the professional athlete often incurs injury due to overuse, whereas the recreational or amateur athlete often becomes injured due to poor mechanics. An understanding of the demands of the golf swing on the body is necessary when rehabilitating a golfer after hip surgery, and close collaboration with a golf professional is vital to help establish good mechanics and avoid excessive forces across the hip joint.
Each golfer’s physical and swing-related strengths and limitations vary, and each should be assessed individually to determine if hip range of motion deficits exist and to what extent. However, here are several things that can help your golf client with back pain.
Just as pelvis positioning is important for normal posture, a neutral pelvis position is important in the golf stance. The golfer should not have an exaggerated lumbar lordosis which can place increased stress on the lumbar facets as well as reduce available space at the femoroacetabular joint. Additionally, they should have a good hinge hinge position, lowering their club to the ground mostly through hip flexion rather than thoracic and/or excessive knee flexion.
Gluteal/posterior chain strength
Proper activation and strength of the gluteus medius and maximus are vital in golf to achieve and maintain a good hip hinge throughout the swing. Additionally, the ability to effectively transfer energy from the ground to the club head relies on the power generated by lower body and gluteals.
If your golfer is lacking hip rotation, you must first determine the cause of that restriction (capsular vs. extra-capsular soft tissue vs. bony). Joint and/or soft tissue mobilization techniques should be utilized when appropriate to help correct the deficit. In the case of those people with bony restriction or perhaps a joint replacement, accommodations can be made in the swing to facilitate hip rotation. Have the golfer flare (externally rotate) their foot on the affected side in their golf stance. By starting in an externally rotated posture, the golfer has more relative hip internal rotation to turn in their backswing (trail leg) and turn fully into their lead leg in the downswing. This saves the back from having to excessively rotate to compensate for lack of hip rotation.
Make sure to thoroughly evaluate all your golfers with back pain, especially assessing hip rotation, posture, and posterior chain strength and treat or correct based on their individual limitations. Your golfers (and their backs!) will thank you.
- Van Dillen LR, Bloom NJ, Gombatto SP, Susco TM. Hip range of motion in people with and without low back pain who participate in rotation-related sports. Phys Ther Sport. 2008;9(2):72–81.
- Vad VB, Bhat AL, Basrai D, et al. Low back pain in professional golfers. Am J Sports Med. 2004;32(2):494-7.
- Newman JT, Saroki AJ, Briggs KK, Phillipon MJ. Return to elite level of play and performance in professional golfers after arthroscopic hip surgery. Orthop J Sports Med. 2016;4(4):1-3.