Swing Technique Change and Adjunctive Exercises in the Treatment of Wrist Pain in a Golfer: A Case Report

Over recent years, biomechanical analysis of the golf swing has led sports medicine and sports science professionals to proffer an ideal technique. The focus has been on understanding those anatomical alignments that create reduced physical stress in load-bearing structures, while still providing the potential for optimal performance. This is borne out of the premise that all athletes have a desire to perform near their maximum while not compromising their longevity.

This paper outlines the treatment of an elite golfer who had left-wrist pain that caused him to withdraw from the Professional Golfers' Association of Australia (PGA) Tour for 14 months. Clinical examination of the wrist injury and elucidation of the mechanism of injury proved enlightening. Importantly it was the establishment of the link between presumably long-term technique flaws and predisposition to the wrist injury that ultimately led to effective intervention. As a basis for explaining the treatment approach taken with this golf player, this chapter describes the salient features of the clinical interview, the physical examination, and the analysis of the data derived from the examination which is interpreted in light of current knowledge of the golf swing and wrist injuries. 

The male golfer presented to our clinic in July 1999 and described his major concern as wrist pain that was worse over the ulnar aspect. On occasions he also experienced pain over the dorsal/ventral, radial aspect of the wrist. The pain was provoked when pushing up from a sitting or lying position on the ground. The pain was not present at rest but could be intermittently provoked by squeezing the carpal bones with his other hand, hitting golf balls, pushing up from a chair, and by placing the hands on the hips with the fingers spread. At worst he rated his pain as 6 on a 10-point visual analogue scale for pain where a score of 10 is the most severe pain imaginable.

There was no elbow, forearm or shoulder pain nor paraesthesia nor numbness in the upper limbs. There was some mild left-side cervical and thoracic soreness over the previous 18 months but this did not appear to be related to the original injury or the wrist pain — rather it appeared to be related to a change in mattress.

The player’s history highlighted a single episode of left-wrist pain at 16 years of age when he sprained the wrist following a fall onto an outstretched arm. He was able to play a junior tournament, in pain, but with the wrist strapped. The pain subsided over 3 weeks. He was left with no residual symptoms following that injury.

The recent injury, for which treatment was being sought, occurred during a routine swing with the driver in May 1997 while playing a PGA Tour event. The shot did not involve the taking of a divot or even contact with the ground. Pain was felt on the dorsal/ventral radial side of the wrist 1 centimetre distal to the radial styloid. The pain was reported as sharp and deep as it was not palpable. The pain did not recur during that round. At that stage slight pain could be reproduced with circumferential pressure to the carpal bones.

The symptoms became increasingly pronounced over the next 10 weeks at which time a chiropractor diagnosed tendonitis. Rest was recommended but not heeded. On returning home, pain was experienced two to three times per round. The golfer was playing at least 4 days per week. A sports general practitioner was consulted and a plain film was taken and showed no abnormality. Physiotherapy treatment was commenced and included carpal mobilisation and wrist strengthening. Strengthening exercises were completed over 4 weeks up to the Tour Qualifying School. The symptoms appeared to be resolving until they were exacerbated by practice on a hard surface prior to Tour School. The player then attempted to play in the Tour School qualifying rounds but was forced to withdraw during the second round. Pain was being experienced with every shot. A single dose of oral corticosteroid medication the previous night had decreased the pain prior to playing the second round. At this time the pain had progressed to involve the proximal ulnar side of the wrist and caused the dorsum of the hand to ache down to the level of the metacarpophalangeal joints.

Subsequently, the golfer rested for 4 months. He attempted to play on 15 occasions during 1998. The symptoms were decreased but still evident particularly with the driver. He recommenced practising in April 1999, but pain was experienced with every shot by June 1999 when he attempted a return to competition. He consulted a sports physician who requested further x-rays and an ultrasound that showed no abnormality. He was referred to a golf specialist physiotherapist (MD) for assessment and treatment. 

Observation revealed a fit, 28-year-old male in excellent health. There was no obvious swelling over the wrist or hand. Active movement was pain-free except at the end of ulnar deviation. There was a slight loss of range into extension and ulnar deviation. Grip strength testing on a dynamometer demonstrated symmetry between left and right sides to within 10%. Manual muscle testing revealed a relative weakness of radial deviation on the left side compared to the right.

Examination with specific stress tests for the wrist region revealed signs consistent with a general synovitis of the region (LaStayo & Howell, 1995; Skirven, 1996). The original radial-side pain was reproduced with passive gliding of the scapho-trapezium joint. There was some sensitivity to palpation of the peri-scaphoid structures, however the scaphoid shift test was negative. The ulnar-side pain was evoked with testing of the triangular fibro-cartilage complex and the distal radio-ulnar joint. The distal radio-ulnar joint exhibited some laxity and joint crepitus. No evidence of ganglion could be found on the clinical examination.

In addition to the conventional clinical evaluation, the golfer’s current swing technique was evaluated from video footage. Particular note was taken of the position at address, swing path and the impact position. At address, the golfer stood with his hands elevated and forward, placing the left wrist in flexion and ulnar deviation. This posture places the major extension-producing muscles of the wrist, especially extensor carpi radialis brevis, in a weak position (Lieber & Friden, 1998; McCarthy, 1999). During takeaway, the golfer took the club away vertically and finished across the line at the end of the backswing. The natural motion of the torso from this position is to come over the top with the right shoulder and arm, resulting in a sharply descending blow (characterised by deep divots). In an effort to prevent this outside-to-in swing path, the player’s wrists were dropped inside the target line (at the start of the downswing) and the left wrist was bowed. At impact, the amount of compensatory left-wrist extension was large. A sweeping action, where the ball was picked off the turf, was evident as the player attempted to minimise the stress on the wrist at contact. Upon further questioning, the golfer clarified that his impact position had been altered in an attempt to limit the original (radial) wrist pain. This movement involved rapid extension of the left wrist and supination of the forearm immediately following impact. A crossover of the forearms early in follow-through characterised this motion. 

The risk of wrist injury in golf, especially the left hand, is reasonably high as it occurs in 26.7% and 20.1% of professional and amateur male golfers, respectively (Barton, 1997; Cahalan, Cooney, Tamai, & Chao, 1991; McCarroll, 1986; McCarroll & Gioe, 1982; Murray & Cooney, 1996; Sherman & Finch, 1997). A number of risk factors have been identified. For example, the high frequency of practice has been linked with the occurrence of overuse injuries. Hitting objects other than the ball such as the ground, inadequate warm-up procedures, and poor swing mechanics have also been implicated (Cahalan et al., 1991; McCarroll, 1986). With regards to swing technique, it is generally agreed that optimal technique meets the goals of maximum performance and minimal injury risk. Optimal swing technique implies minimal variation from the ideal pattern of movement. It is generally regarded that any significant variation from this optimal swing results in a higher risk of injury (James, 1995; Kohn, 1996; McCarroll, 1986; Stover & Mallon, 1992), although this has yet to be proven (Mallon & Hawkins, 1994; Stover & Mallon, 1992). Correction of swing mechanics, which includes addressing all body segments from the foot up, has been advocated as a means by which to ameliorate acute and chronic golfing injuries (McCarroll, 1986; Pietrocarlo, 1996). 

Following examination and the analysis of the findings in light of current knowledge of swing technique and injuries in golf, it was decided that the golfer should return to his coach with the recommendation that his impact position and swing path be reviewed. Crucially, this request would only be fulfilled if it proved consistent with the desired technical direction of the coach and golfer, which in this case it was. In addition to the technical advice, the golfer was instructed in the use of supportive taping and a resting splint (Prosser, 1995). The golfer was advised to employ these devices when he returned to practice on a daily basis. The role of strengthening for wrist and forearm muscles was discussed with the golfer.

Initial intervention by the coach was to alter the address position. This change was followed by a flatter takeaway and wider angle of attack to the ball. The change in swing technique involved an increase in trunk rotation. This was supplemented with swing-technique-specific stretching exercises devised by the therapist and coach. Within 1 week of daily practice, hitting approximately 100 balls per day, the pain was not being experienced during most practice drills and only occurred on two occasions when using a driver. Practice was increased slowly and supplemented with golf-specific posture exercises devised by the therapist as well as specific technique drills by the coach.

A review 6 weeks after presentation revealed a marked reduction in pain on all tests. Pain was reported as less than 1 on the 10-point visual analogue scale for self-reported pain intensity. Only scapho-trapezial gliding and triangular fibro-cartilage complex load tests were reported as mildly symptom provocative as opposed to strongly provocative at the initial examination. On a daily basis, the golfer reported an awareness of his wrist but was able to practise unimpeded. He hoped to regain his playing card at the Tour School in October. 

Three distinct features appear to characterise this injured golfer’s presentation. Firstly, the initial trauma to the left wrist during adolescence may have left him with some residual painless joint problem. Secondly, the technique analysis highlighted a steep vertical takeaway, an inside-to-out swing path to impact and a bowed left wrist at impact. Repetition of this movement could result in irritation and eventual synovitis of the peri-scaphoid and distal radio-ulnar joint tissues. Thirdly, it is postulated that in an attempt to limit the pain, the golfer may have altered his impact and follow-through position such that the wrist underwent rapid left-wrist extension, ulnar deviation and forearm supination. This action created the crossover position previously described. The resultant repeated compression and shear within the distal radio-ulnar joint and triangular fibro-cartilage complex could have produced the more recent ulnar-side symptoms.

The intervention, a change in swing technique and adjunct exercises, was associated with a resolution of a chronic problem, probably as a result of altered stresses at the wrist joint and soft tissues. The alteration in stresses allowed the resumption of pain-free playing. With subthreshold stress on the irritable structures, the golfer was able to gradually return to golf. 

The purpose of this case study was to highlight an unusual therapeutic intervention strategy in the treatment of a golfer with wrist pain. The case reported here involved a touring professional who was unable to compete for 14 months. For the clinician, a knowledge of optimal swing mechanics, the anatomical structures involved, and the likely progression of the pathology were important factors in the treatment of this player. A change to the swing technique, promotion of a rotational action of his trunk, hip and shoulder, an approach to the ball in line with the target, a neutral wrist position, and reduced supination of the left wrist led to excellent ball striking without pain. The player’s coach assumed a critical role in the re-education of this player’s swing technique and hence in the treatment program.

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