Tuesday, 22 April 2014

Zebras and Horses and Golf

I gave up playing golf because I figured I could better spend the 4 hours it takes for a round of frustration trying to get up on a surfboard. Whilst the surfing skills have not advanced to the level I might have hoped, I still love golf. Not so much the frustrations of the game, but rather the minutiae that goes into a golf swing. The biomechanics of grip combined with wrist, elbow and shoulder movement add up to a complicated puzzle that is confused even further by injury. Sometimes however, this puzzle is most easily solved by following the "horses are more common than zebras" analogy.

I've seen a particular professional golfer a couple of times now. She too can have the now generic female patient name of Ivy. Ivy initially came in having had a three month history of left wrist and thumb pain that was worst with loaded thumb extension and wrist extension, i.e. down swing and through impact. An MRI showed bruising around the scaphoid and trapezium. Manual muscle testing indicated weakness of the ECRL and FCR, and pinch strength was reduced.

My thinking was that Ivy had developed a mild radial carpal instability, with micro-trauma in FCR impacting on the trapezium as it crosses it, causing the bone stress over time. I've seen this bruising around the trapezium previously in female golfers. Weakness compounds the injury, which forces patterns of the golf swing to alter in a minor way, but perhaps enough to make the pain worse. 


In Ivy's case, she knew that if she didn't extend the wrist as much during the swing, she had less discomfort. I gave Ivy a program of wrist proprioceptive exercises, leading onto muscle specific strengthening to the wrist and thumb. Ivy spent some time with her swing coach, rejoined the tour and reported by email great improvements, until that is, she hit a rock, in China.   

Ivy came back into the clinic yesterday. The wrist pain had gone, now what she had was much more specific to the thumb. Probably related, but different. It was apparent Ivy had worked hard on the wrist exercises. Strength was better, and proprioceptively her control was much better also. What she'd let slip though, were the thumb and hand strengthening exercises. 

Ivy's thumb was now feeling unstable, not clinically, but certainly to her. The left thenar eminence was soft compared with her right hand, and pinch strength was again reduced. Neurological testing was negative. This time, the MRI showed nothing. Now, I could have started looking for zebras, but horses are much more common in Australia, so I focused on the strength. If Ivy can make her thumb strong again, she will be able to keep it stable through her swing. It made sense to Ivy, it made sense to her coach, and it made sense to me. I'll let you know how it pans out.

Look after those fingers,


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