ion. This tends to lead to a shortening of the
shoulder structures with protraction of the shoulder. Pectoralis minor is thought to be the main protractor.
scapular muscles, particularly the rhomboids. This can be seen clinically by measuring the distance between the thoracic spine and the
border of the scapular and comparing this to the same distance in the non leading shoulder. In extreme cases this distance will be increased showing lengthening of the rhomboids and protraction of the shoulder. Clinically a scapular dysrhythmia can also be seen with the shoulder protracting more through
In addition to the muscular effects above the extreme adduct
ed position coupled with underlying joint hyerlaxity leads to excessive posterior
capsular stretch and a subclinical posterior instability
of the leading shoulder. This can progress to posterior labral
tears as well as anterosuperior
internal impingement and subacromial impingement as the greater tuberosity passes very close to the anterosuperior labrum
and under the acromion. The excess posterior
capsular laxity can be assessed by testing internal and external rotation in 90° abduct
ion. One may find excess internal rotation on the leading shoulder compared to the non leading shoulder.
posterior capsular stretch and posterior labral injury in the leading shoulder:|
Internal impingement on the non-leading shoulder exists between infraspinatus and the gleno-humeral joint, due to the extreme external rotation of the golf swing.
A diagnostic algorithm can be applied to both the young and the older golfer’s with a cut off age of approximately 35 years. The younger golfer’s are those that are more lax and more prone to sub clinical posterior instability
pathologies and secondary subacromial impingement. They may also progress to developing partial thickness rotator cuff tears.
The specific clinical findings and examination should be to assess:
- Hyperlaxity with a Beighton score.
- Painful clicking on circumduction of the shoulder.
- Excess internal rotation in abduction compared to the non leading shoulder.
- Positive O’Brien’s test with both pain and weakness particularly posteriorly as the humeral head translates posteriorly in the adducted internally rotated position.
- Subacromial impingement tests including Hawkins’ and Neer’s sign.
In the older player clinical examination should be directed towards:
- Impingement tests: Hawkin's and Neer’s sign.
- Acromioclavicular joint tests: direct tenderness, Scarf test and Paxinos test, rotator cuff tests should also be performed.
In the young patients the gold standard investigation is an MR arthrogram
as this should give a better idea of the capsular laxity and labral
In the older golfer an x ray would be beneficial for AC joint pathology as well as possible impingement signs. Ultrasound scan
is useful for impingement and assessing the rotator cuff and MRI scan may be useful to look for impingement from underlying osteophytes from the acromion, from the AC joint and assessing the rotator cuff as well as possible large osteochondral lesions.
In the young golfer with a normal MR arthrogram specialist rehabilitation would be the main treatment. This should include scapular correction exercises, balancing the scapular protractors and retractors as well as sports specific rehabilitation. Core stability and working on the kinetic chain particularly for golf is essential.
Should the MR arthrogram confirm a labral tear arthroscop
ic repair would be appropriate. However significant tightening of the posterior
capsule is not recommended as this will significantly delay or restrict a return to golf.
In the older golfer the standard treatments for impingement, AC joint arthritis or rotator cuff pathology as found would apply.
Return to golf rehab post operative and post injury rehabilitation can be directed to sports specific return to golf rehab from a very early stage.
At three to four weeks following surgery or standard rehabs one handed putting with the affected arm can be started, putting through the lane by lining up shots using string instead of clubs can be done.
The swing can be recaptured and very early on by performing simple body twisting exercises reproducing the swing motions and working on core stability and kinetic chain in this way. The sport can be brought into the therapists gym by using therabands to reproduce the golf swing.
Short game strokes and ball hitting can start generally by the end of the second month with increased shoulder stretching particularly working on any tightness either anterior
ly or posterior
ly to return the normal golfing motion in the shoulder joint. Golf drills can generally start at the second or third month and the player return to the pre-teaching pro at that stage under guidance and with good communication from the physiotherapist and surgeon.
There should be good communication between the patient’s surgeon, physiotherapist and the teaching pro at all stages.
Shoulder injuries in golf are common. They are unique to each shoulder and also to golf. The awareness of sub clinical posterior instability
in the non leading shoulder is increasing and a good multi-disciplinary treatment at all stages is the ideal management for an early return to golf.