There is an
old saying that goes; “It is not the notes that make the music, but the spaces
betwee the notes that make the music beautiful”. This quotation can be applied to the
relationship between the golf swing, and the paces between the golf
swings. It would go something like this;
“It is not the golf swing that creates chronic pain in the golfer, but the
paces between the swings that are the root cause of the chronic pain”. The understanding of the meaning of this
concept is critical in the clinical application of orthotic therapy in
golfers. Read on to discover how you can
have a real impact on the health and wellness of your golf patients and
revolutionize your practice as well.
It has been
calculated that in an 18 hole round of
golf, the average golfer will spend approximately 3
hours walking, 1 hour preparing to hit the ball and only 4 minutes actually swinging to strike the
ball! Therefore, I draw the conclusion that chronic injuries in the lower
extremity, pelvis and spine, may not be related to the golf swing itself, as
much as they are related to the chronic stress placed on the weight bearing
joints during the 3-4 hours that it takes to walk 18 holes of golf. The following describes the underlying
principles to support this hypothesis.
Biomechanical
weaknesses in the foot can be the root cause of chronic musculoskeletal
conditions in the foot, ankle, knee, hip, pelvis and spine. Correcting these
biomechanical weaknesses is the key to resolving chronic conditions in the
golfer, or any patient suffering with chronic pain. Functional Orthotic Therapy (FOT) in clinical
practice is defined as, the prescription of foot orthoses (shoe inserts) used
for the support and correction of these biomechanical foot faults. A variety of practitioners use arch supports
and/or orthotic devices in the management of foot/ankle complaints, however,
this discussion is primarily related to the use of orthotic devices in the
management of chronic conditions throughout the entire closed kinetic chain,
including the lower extremities, pelvis and spine. These conditions
are commonly seen in clinical practice. FOT can be incorporated as part of an overall
plan of management that may also include manipulative therapy, physiotherapeutics,
functional rehabilitation, etc.
Abnormal
torsional forces placed on the joints and soft tissues during the walking gait
cycle are related to the underlying biomechanical faults in the closed kinetic
chain of human locomotion. As an
example; typically golfers present with chronic, recurring, ankle, knee, hip, sacroiliac,
lumbosacral or lumbar facet syndrome / joint dysfunction, with associated
ligamentous, tendinous, and muscular irritation. In the case of a chronic complaint, manipulation,
physiotherapeutics, and rehabilitation usually provide varying levels of relief,
for varying periods of time. When a golfers
condition does not resolve with standard treatment, consider the potential
underlying biomechanical weakness that may be precipitating the chronic
irritation to the joints and soft tissues.
In many cases, you will find that there is an asymmetrical pronation of
the feet, both statically and dynamically.
Bilateral asymmetrical
pronation syndrome (BAPS) is a common finding in patients with chronic
conditions of the weight bearing joints.
When one foot pronates to a greater degree than the other, torsional
forces impact the weight bearing joints up the kinetic chain, as a function of
ground reaction forces.
Imagine that the right
foot overpronates. This causes the tibia
to internally rotate, the femur to internally rotate, the right ilium to rotate
anteriorly, the lumbar spine to rotate body left (spinous right), the thoracic
and cervical vertebrae also rotate in the same direction, and as a result of
cervical left rotation, the coupled motion results in cervical left lateral
flexion.
Now, go back
through that whole sequence of events in the joints, and consider how the soft
tissues would have to adapt and respond to compensate for this excessive
torsional stress at each of these joints.
Most commonly this phenomenon results in medial longitudinal arch pain,
medial knee pain, lateral hip pain, bilateral sacroiliac pain, and most
commonly, pain at the transitional regions of the spine. (SI, L/S, T/L, T/C and
C0/C1) Therefore, although a standard regimen of treatment may give temporary
relief, it is not uncommon for our golf patients to return with a chronic recurrence
of the signs and symptoms associated with their chronic conditions. Remember that the site of chronic
pain is often not the source of the pain. Therefore, we are
compelled, by professional integrity and clinical curiosity, to investigate all
of the possible aetiologies contributing to the patient’s condition. Once we identify the true cause of the
complaint, we can apply the appropriate clinical interventions to achieve
resolution of the condition. Functional
orthotic therapy can be a highly effective management tool in facilitating the
correction of these underlying biomechanical faults and ultimately helping the
patient to realise relief from his/her chronic musculoskeletal condition.
This
knowledge may modify the way you examine a patient. In taking a history you will want to listen
for clues about how the patient’s condition manifests in their activities of
daily living. Patients with an
underlying biomechanical weakness will often have an increase in symptoms late
in the day, have lower extremity joint pain, in addition to pelvic and spinal
pain, and will have an increase in symptoms with long term standing, walking or
running. Golfers will note that they are
a bit stiff when warming up, feel OK on the front 9, but experience a gradual
increase in symptoms over the last few holes. They may also indicate a past
history of plantar fasciitis (arch pain), posterior tibial disorder (shin
splints), generalized knee or hip pain that is episodic depending on the
frequency, intensity and duration of their golf activities.
Observation
of the static posture will reveal bilateral asymmetrical pronation of the feet
with associated internal tibial rotation and “squinting” patellae, pelvic
obliquity, scoliotic - like flexion /rotational changes in the spine, shoulder
unleveling and head tilt. I have found
that most practitioners have been taught to observe posture from the top
down. I would challenge you to consider
examining from the ground up, and to observe how the changes in the posture of
the feet can influence the rest of the structures up the kinetic chain. Furthermore, you will want to observe the
golfers posture at address, full back swing and full follow through. Overpronation
of the feet will lead to restrictions in lower extremity rotation at the
beginning and end of the swing. Resulting
in abnormal compensatory movement elsewhere.
On physical
examination, you will often find that the classic orthopedic tests are negative,
or not true positives. We have all seen
knee, hip and low back pain patients with no true positive orthopedic or
neuralgic tests, but who clearly have dysfunction in the joint(s) of interest
that we can identify with palpation, other signs and symptoms, and by history. You may also find that many of these patients
characteristically have palpatory tenderness in the medial knee, lateral hip,
and paraspinal soft tissues in the transitional areas of the spine (SI, L/S,
T/L, C/T and C0/C1).
Once you have
decided that your golf patient would benefit from FOT, the next step is to
decide what type of device to prescribe.
There is a wide spectrum of sophistication regarding the types of
orthotic devices available to practitioners.
The patient with an uncomplicated case of plantar fasciitis may well be
helped with a simple over the counter (OTC) device, which will provide basic
arch support for the medial longitudinal arch and offer relief. However, the patient with chronic recurring
sacroiliac, lumbosacral and thoracolumbar dysfunction will
require a customised, or custom pair of biomechanical devices to correct the
dysfunctional relationship between the rearfoot and forefoot, as well as
supporting the arch. In general, the
further up the kinetic chain the condition manifests, the more sophisticated
the device that is necessary to correct the underlying biomechanical
faults. Orthoses purchased OTC by the
patient do not require any specific measurements other than size. However, with a customized or custom device,
some form of measurement or impression is necessary to satisfy more exacting
requirements. Orthoses can be customized
through the use of heat molding, fluid injection, or foam impressions. In these cases a basic orthotic template is
modified in an attempt to individualize the orthoses to the patient’s feet.
There is also
digitized pressure plate analysis which generates a digital image of the
pressure patterns created through the weight bearing portion of the gait
cycle. This pattern is then used to
generate a customized device to match the patient’s foot function and provide
dynamic support. Finally, plaster casting
is used to create a negative impression of the foot. This negative impression is used by a lab to
either fill with plaster to make a positive impression, from which the orthotic
is manufactured, or it is scanned with a CAD/CAM system to create a digital
positive impression that is used in computer assisted manufacturing of the
device. This, however, generates a
non-weight bearing impression that does not account for dynamic forces through
the foot. There are advantages and
disadvantages to each of these methods of capturing the function, impressions
and contours of the foot. In addition,
there is ongoing debate regarding the relative benefits of weight bearing
versus non-weight bearing measurements / impressions. Also, there is the question of the types of
materials used to manufacture the orthotic devices. These debates are too detailed to address in
this article. However, in my experience, they will all work with varying degrees
of success in the hands of a properly trained professional. I hasten to note that proper training is
readily available and easy to achieve for most practitioners of musculoskeletal
health care. What is most important in incorporating
FOT in clinical practice, is a solid base of basic anatomy and
biomechanics along with some common sense, wisdom, good clinical judgment,
compassion for the patient, and a clinical curiosity to seek out the best
solution for the patient.
Over the past
15 years, as I have presented lectures, seminars and workshops on the subject
of FOT, practitioners want to know which system I use. The answer is that I have used them all at
one point or another in my private practice.
For many years I used non-weight bearing, neutral position plaster
casting as the only method for prescribing orthoses. This method is very time consuming, labor
intensive, and messy, but was the best method at the time. I attempted using heat molding, injection
molding, foam impressions, and a variety of systems wherein a basic template
was modified with various forefoot and rearfoot posts. Again, all of these systems worked with
varying degrees of success. However,
they were all time consuming in one way or another or have a relatively low
level of specificity. With golfers,
specificity is critical due to the challenge of walking 5-6 miles on grass,
with an unpredictable surface, requiring a great deal of intrinsic adaptation
from the foot. In addition, a few
millimeters of overpronation can lead to a marked limitation in swing
mechanics.
In the last
few years I have been introduced to digital pressure plate scanning as a method
for prescribing orthoses. I now use this
method almost exclusively in my private practice. It takes just a few minutes to scan the
patient, the results are sent electronically to the lab, and the customised
devices are delivered within 10 days to the office for dispensing to the
patient. The devices do not require any
further modification as they are individualised to the patient. On rare occasion I see a patient that I feel
requires a fully custom device. In this
situation I cast the patient to generate a negative impression of the patient’s
foot, along with the pressure plate analysis.
The cast is mailed to the lab and the digital data is sent
electronically as usual. The lab then
can combine the data from the digitised scan with the data that they generate
when they scan the negative cast with their CAD/CAM device. Then a fully custom pair of devices are
generated. This process takes longer due
to the mailing, and therefore is only use with patients who have gross
anatomical or functional anomalies, or for elite athletes with special
needs. In general, the vast majority of
my patients do very well with a digitised scan and the customised device that
it generates. Furthermore, the graphics
that are instantly available as a paper print out, facilitate patient education
and compliance.
The addition
of FOT to your treatment regimen of manipulation, physiotherapeutics and
rehabilitation will revolutionize your practice. I encourage every musculoskeletal
practitioner, to spend the minimal time, effort and money that are required to
add this very powerful modality to your clinical practice. I hope that this article stimulates your
clinical thinking. Please contact me
with questions or for information about upcoming seminars in your area, or the
addition of the GaitScan system in your practice.
Dr. Cherye Roche is qualified Sports Chiropractor. She is in private practice in Albany and
Auckland, NZ. She is a registered Doctor
of Chiropractic in the USA, UK, Australia and New Zealand. She is a Fellow of the College
of Chiropractors, Fellow of the European Acadamy of
Chirorpactic, exercise physiologist, certified athletic trainer, University
lecturer, and international lecturer on clinical orthotic therapy in
musculoskeletal health care. Inquiries can be sent to her directly at:
