Course Instructor (P9)
Hip And Pelvis Injury
The hip and pelvis play an important role in the stabilization of the golfer through the power phase of the swing. Flexibilityat the hip is a key benefit to the golfer and is important in decreasing the chance of injury that will be translated to other contiguous areas, like the lumbar spine and knees.
The hip is the strongest joint in the body due to the arrangement of bones, ligaments, muscles and tendons. Of course this is a ball-and-socket joint formed as the spherical head of the femur articulates into the deep socket acetabulum of the ilium. The osseous structures of the ilium, ischium and pubic area, along with the sacrum and coccyx, comprise the pelvis. The supporting ligaments are made up of the ligamentum teres, transverse, acetabular, iliofemoral, pubofemoral and inguinal ligaments. Along with muscular attachments, these structures will transfer weight between the torso and the lower extremities. There is a multitude of muscular recruitment patterns to manage motion of the hip. Flexion is managed by the iliacus, rectus femoris and sartorious all supplied by the femoral nerve emanating from the segmental levels of L2 and L3. The adductor brevis and magnus (which have a greater contribution when the hip is already extended) are supplied by the obturator nerve and emerge from L2 and L3 segmental levels. The psoas muscle is segmentaly supplied from the plexus emanating from L2 through L4 levels. The remainder of flexion is conducted by the femoral nerve (accessory obturator) or the L2-L3 level and the tensor fascia latae fed from the superior gluteal nerve and L4 through S1 levels
Extension is managed with the firing of the gluteus maximus, supplied by the inferior gluteal nerve and segments L5 through S1. The long head of the biceps femoris (L5 through S2) the semimembranosis and semitendonosis are all conducted through the sciatic nerve with the last two supplied by L5 and S1. The gluteus medius is supplied by the superior gluteal nerve at L4 through S1 and finally, the abductor magnus is fed by the sciatic nerve from the L4 and L5 levels.
Abduction is conducted from the superior gluteal nerve and L4 through S1 for the management of the gluteus minimus and medius and tensor fascia latae and again, the gluteus maximus and the sartorious.
Adduction is managed by the adductor brevis and longus, fed by the obturator nerve and the adductor magnus (fed by the obturator and the sciatic nerve). The pectineus is supplied by the femoral nerve at the levels of L3 and L4. These levels also supply the obturator nerve and the muscle function of the gracilus.
With golf the likelihood of avulsion fracture, general fracture or complete tears and contusions from normal play is very low, but a myriad of motion or nagging injuries are common.
- Trochanteric Bursitis– the cause of this condition is a snapping of the iliotibial band over the greater trochanter. This occurs at the bursae sac at the gluteus medius/iliotibial band intersection at the greater trochanter. Repetitive play, walking the course on uneven surfaces, and pulling a hand cart can all contribute to this irritation. Obviously, the sooner this is detected, the sooner an application of rest, ice, compression and support can be applied. Most likely, this is discovered in the sub-acute or chronic phase, when the use of heat and supervised stretching are most affective.
- Hip Strain – this commonly occurs when the joint undergoes a violent twisting motion of the torso accompanied by the feet being fixed in a stationary position. This, of course, is a great description of the swing action in golf. When evaluating a possible hip strain, have the patient perform various movements like flexion, extension, adduction and abduction, as well as, circumduction motions. The more acute the discovery, the easier it is to apply a principle of support and stabilization, but chronic management will clearly become rehabilitative and require modifications of activity and restorative exercises.
- Iliotibial Band Syndrome – the iliotibial band originates on the iliac crest and inserts on the lateral tibial condyle. This condition is usually due to an overuse-syndrome, occurring when the fascia latae repetitively snaps over the lateral femoral condyle. This is more common in runners than golfers, but it can have an impact on performance and can become chronic if unattended. The most difficult part of managing this is that it will require a significant modification of activities. Something golfers do not like to do. Conservative care programs will emphasize a decrease in inflammation and encouraging a protocol of stretching with gradual return to activities and retooling body mechanics, or even using orthotics.
- Groin Pull – usually this is a strain of the psoas muscle because the individual has not employed proper stretching techniques. It is important to rule-out other problems like hernia, back instability, prostatitis, urethritis, nephrolithiasis or testicular torsion, since some of the symptoms overlap. There will most likely be point tenderness over the groin. There will be little pain on passive movement, but pain will occur during active hip motion. In the acute phase, it is necessary to control the hemorrhage, pain and spasm for approximately 2 to 3 days with ice and rest. Stabilization can be done with a 6 inch wide elastic hip spica (a figure 8 bandage that generally overlaps the previous portion to form a V-like design). In the second phase of management, between 4 to 6 days, pain and spasm control continues and restoration of full ability is encouraged. The therapy modalities will include ice, massage, and muscle stimulation above and below the pain site (approximately 5 to 10 minutes). Proprioceptive neural facilitation at 3 to 4 times per day is suggested with optional jogging in place for 10 minutes or so. The third phase is directed at resorting strength and flexibility, while managing inflammation. This can be accomplished with muscle stimulation using surge current to tolerance with ultrasound. Active therapy is continued including PNF and progressive-resistance exercise. The patient can use ice packs or ice massage after the exercises, if required. The fourth goal is to return the patient to full power, speed, endurance and flexibility. Light jogging may be used in this phase. Finally, the fifth goal is to return the individual gradually to the sport while using protection, like a hip spica bandage for a short while. Measure full function and capacity by comparing the injured side with the uninjured side through strength and range of motion testing.
- Slipped Capital Femoral Epiphysis – this is a low possibility, but youth participants in golf are increasing. This would most likelyoccur with obese males in the age range of 9 to 15 years. There will be pain and gait changes present as the femoral epiphysis slips off the metaphysis. Of course, though rare, this can be severe if it develops into avascular necrosis.
- Degenerative Joint Disease – the opposite end of the age spectrum from the previous condition is degenerative changes. The senior golfer is often impacted by restriction developed over time. The treatment is supportive and preventive. Usually, it is centered on modifying the frequency of play and influencing the range of motion, both passively and actively.