Kam Bhabra is a specialist sports physiotherapist who has worked with Champions League soccer players and PGA Tour Golf Professionals. For the past 5 years he has been physiotherapist and conditioning specialist for PGA Tour Pros – Justin Rose, Ian Poulter, Ben Curtis, Frederik Jacobson and Brian Davis. PhysioRoom.com caught up with him to find out more about golf injuries at elite level.
Which golfers do you work with as a physiotherapist and fitness trainer on the PGA Tour?
“I currently work for Justin Rose, Ian Poulter, Ben Curtis, Frederik Jacobson and Brian Davis.”
Does this mean that you have to follow them around the world as they play in tournaments?
“To an extent, however they all play predominantly on the PGA tour in the United States. This means most of my time is spent following this tour around the US. However I do come to Europe for the bigger events such as the Open and the PGA, as some of my players will have such events scheduled into their year. I try to cover about 20 events per player (i.e.. about 70 per cent of tournament play) to keep some consistency for each player.”
Because you’re traveling so much, how do you deal with referrals to specialists if the players require them?
“Difficult one, but often word of mouth is always good! Most of my players base themselves out of Orlando and we have made good contact with Doctors and Specialists in the area, they deal with other sporting athletes and teams having access to first-class facilities and technology.”
What are the common golf injuries that you have to treat?
“From my perspective working with a small select group of players and predominantly on injury prevention, it is difficult to say what the most common injuries are in golfers. Certainly what has been found over the years is that any part of the body can be affected in golf, probably due to the range of movement and the repetitive rotational stresses that are placed throughout the body. The following are some examples of injuries that I have encountered over the years and a brief description of their management.
“Low Back Pain – L5/S1 inter-vertebral disc bulge and irritation due to continual flexion and rotational loading, placed upon this region. Management involved Chiropractic adjustment to set the sacrum and reduce the disc bulge. Physiotherapy treatment was required to release tight and adhered myo-fascia of the global mobilizing muscles such as hamstrings, Tensor Fascia Latae, IlioTibial Band etc. Core strength training is important to develop control of local and global stability muscles, especially rotational control of the lumbo-pelvic region. Another important objective of physio treatment for low back pain in golfers is to improve the function of posterior oblique, longitudinal, lateral and anterior oblique slings, that provide force closure to the lumbo-pelvic area (Gibbons and Comerford 2001). Improving hip function and gluteal control to off load torsional (twisting) forces on the pelvis is also important.
“Shoulder Pain – Another important area to observe is right shoulder internal impingement affecting the Supraspinatus and Infraspinatus tendons of the Rotator Cuff. This can occur due to tight and overactive posterior structures of the shoulder. Because of the mechanics of the golf swing the lateral rotators and posterior capsule become tight altering the motion of the shoulder joint. In external rotation the head of the humerus (upper arm bone) is pulled backwards and upwards due to the tightening of the posterior structures; and this causes Impingement Syndrome. This responds well to soft tissue release of the lateral rotator muscles of the shoulder and stretching. Other areas for the physio to work on include mobilizing the posterior joint capsule, developing good Scapula (shoulder blade) control and Rotator Cuff muscle stability.
“Hip Pain – Left hip anterior (front) impingement due to tightening of short Adductor muscles, Iliopsoas and External Rotator muscles of the left hip. The left short Adductors become overactive by pulling the pelvis through in the right-handed golf swing. Also the left Hip Flexor muscles and Hip External Rotator muscles become tight and overactive, as they eccentrically contract to decelerate the left hip on the follow through in the swing. Soft tissue release and stretching of the tight areas mentioned, along with mobilization of the hip joint is usually effective in relieving symptoms.
“Tennis Elbow (Lateral Epicondylitis) to the left arm is often due to impacting hard ground; the grip being too small or a sudden increased work load causing tissue failure. Tennis Elbow is a typical tendon lesion that needs rest and a chance to heal. Alteration of small grips to larger ones ensures that there is not too much tension in the forearms, by off-loading the common extensor tendon. Adjusting workloads and practicing on softer ground may also help to reduce irritation, even using a tee peg to practice off, when Tennis Elbow is irritated during ball strike. Treatment involves Ice Therapy, Anti Inflammatory medication, myofascial release of the extensor muscles, neural mobilization and eccentric strengthening of the tendon and attachment.
“Shin Pain – Left leg Peroneal tendonitis due to overuse or new golf shoes altering foot mechanics. Management of this condition requires rest by reducing workload or using old shoes. Treatment includes ice, Anti Inflammatory medication, myofascial release of the Peroneal muscles, neural mobilization, eccentric strengthening and proprioceptive exercises to improve ankle and foot stability.”
What are the key areas of injury prevention for golfers?
“Warm up is the first key area that has been addressed. In any sport this is probably one of the most importance aspects of injury prevention – “prepare to succeed, or prepare to fail”. Our belief is to really utilize the term warm up, using movements and exercises that are related closely to the golf swing. For example, simple exercises such as overhead squats, hip swings, rotational exercises for the upper torso using bands to get the body moving taking muscles and joints through functional range of movement. Ideally we are trying to wake the nervous system up by firing motor patterns related to the golf swing, so by the time the players reach the range they feel warm like they have been hitting balls for 10 minutes already. When they start hitting balls good motor patterns have been switched on, lessening the likelihood of bad swings and injury due to poor preparation.
“Flexibility is another key area in injury prevention, where passive stretching is generally reserved for post play to help normalize muscle and postural tone aiding recovery. However we do stretch passively prior to play, but lightly and only key areas prone to tightness in golfers. These areas working from the ground up include Soleus, Hamstrings, Tensor Fascia Latae and IlioTibial Band, Iliopsoas, short adductors, Piriformis, Quadratus Lumborum, Erector Spinae, Lats, Pectorals, Levator Scapula and upper cervical extensors. The muscles mentioned are pre-dominantly global mobilizers and as Janda (1985) states they are prone to shortness and over activity. Depending on each individual we vary the amount of active and passive involvement during the warm up, some guys prefer to do more passive stretching and others more exercising. My belief is more active preparation and care taken not to over stretch passively, potentially losing feel and power prior to performance.
“Recovery is my next role, using hold-relax stretching and soft tissue mobilization incorporating a variety of techniques to aid myofascial (muscle and fascia) mobility and recovery. As mentioned the whole body in golf is prone to developing tightness and adhesions due to overuse. In particular the spine, pelvis and hips seem to be the area that requires most attention, possibly due to their vital role of connecting the lower body and ground reaction forces to the upper body and the golf club. Hence the need for strong well controlled core, this can be related back to normal movement and the importance of developing control of the central key point (the trunk). Any fine movement of the extremities will be compromised if we do not have this central control, this can be related back to the highly skilled nature and coordination of golf.
“Good posture with core stability, maintaining body alignment and control, will help to balance the flexibility training, as a strong core is essential to help maintain a good spinal angle in the golf swing allowing consistency and control. Working alongside the best golf coaches in the world, one of the first key fundamentals they work on is posture and alignment. This area of injury prevention compliments the basis of their work, encouraging a good platform. Golf is a sport that requires high levels of control and consistency, if the body has good alignment then skilled motor patterns are more easily attainable and repeatable. Much time is spent on teaching good posture and when training this is reinforced encouraging quality of movement.”
You’re also responsible for the players’ fitness and conditioning. What are the most important aspects of golf fitness that you work on?
“Some of the areas already mentioned such as flexibility and core stability overlap into the area of conditioning. Warm up pre-work out and stretching post-work continue the theme of flexibility. This is balanced with stability training of the core i.e. primary and global stabilizers of the body. Teaching awareness of Transverse Abdominus, Multifidus and Gluteus Medius muscles to maintain lumbo-pelvic control; developing Scapula (shoulder blade) control and Rotator Cuff muscle strength; and improving ankle proprioception are all key areas of stability training.
“We use a selective functional movement assessment similar to the Titleist Performance Institute (see myTPI.com) to screen each individual player, helping to identify their movements faults and imbalances that can be related back to their golf swing. Then corrective exercises can be used to improve mobility and stability, where required throughout the body. We are trying to promote normal posture and movement, allowing more traditional training methods to develop general strength, speed and power improving performance.
“Strength and power are important aspects of golf now, there are many good young players coming through who are athletes. Golfers strive for more distance now to be competitive. Our strength training involves lighter weights consisting of higher repetitions and speed with good form. Power work is achieved via resistance bands and medicine balls to develop speed as well as strength. Due to my background, emphasis is on control and quality motor patterns to ensure good functional training and to prevent injury.
“The information provided has been developed over a period of years working with elite athletes. It is only my personal ideas on how golf players can be conditioned, and it must be remembered that golf is a very individual sport. There are also several other professionals from different backgrounds that provide physical conditioning to tour players. We all have a common theme, but how we get our results varies from individual to individual.”