Introduction to Pre-habilitation and How it Relates to Golf (Part 2)
“Give me six hours to chop down a tree, and I will spend the first four sharpening the axe.”
- Abraham Lincoln
Golfer’s elbow, back and rotator cuff strains, knee and hip ligament sprains, and other problems occur in both amateur duffers and professionals alike. And then, of course, there is the often-injured elephant in the room: Tiger Woods. With his visibility in the sport, there becomes a greater emphasis on the effects of golf on athletes’ bodies.
The debate then persists, are these injuries due to the “unnatural” mechanics required during a golf swing, the substantial forces translated through the hips and back, inadequate cross-training by injured golfers, or some combination of these with external factors such as weight, age and “trying to swing out of your shoes?” Regardless, injuries are relatively common and can, at best, ruin your game or in worse cases, provoke serious injury. Most people don’t realize the impact that the correct, personalized rehabilitation plan may have on the rate and extent of recovery and risk of reinjury. If the dreaded “s-word” (surgery) enters the discussion, this rehabilitation plan effectively shifts into the early stages of “prehabilitation.”
In most cases, a golf-related injury will heal with time, light activity, and potentially a short course of physical therapy. In more severe cases, however, surgery may be warranted; this is more common for symptoms related to a disc tear or herniation. Think “disc tear” when you hear “annular tear,” which describes the portion of the disc called the annulus fibrosis where the pain-sensing nerves reside. Surgeons may opt to treat these surgically after physical therapy and medications like non-steroidal anti-inflammatory drugs (NSAIDs) or steroids fail to reduce pain while waiting for the injury to heal. These tears are disproportionately painful relative to the size of the injury. Further, they don’t heal very well, and every time you bend forward, the pressure on the disc aggravates the tear. Surgery usually involves a discectomy of some type like a micro/partial discectomy, in which the surgeon only removes the damaged portion and leaves the rest of the disc in place.
If a small tear in the disc could warrant surgery, then a herniation in which the whole “jelly is out of the donut” must be a surgical no-brainer, right? Actually, no, not typically. While a disc herniation involves pushing the soft internal material (nucleus pulposus) through the sensitive annulus, in most cases the potential for recovery with conservative treatment is quite favorable. As a general rule of thumb, the more extreme appearing the disc herniation, the more likely the immune system is to recognize the injury and clean up the mess. Even so, this process can take many months to over a year, so for pain that is unbearable and unresponsive to anti-inflammatory treatments, surgery becomes a reasonable option to discuss with your physician. If a compressed nerve is causing muscle weakness, the prolonged compression during a long recovery period could cause permanent injury. This scenario may also require urgent or emergent surgical treatment.
Assuming the herniation does not warrant emergent surgery, you may have a few weeks between the first meeting with the surgeon and the actual date of the procedure. Often, this is an opportunity to use this time productively, maximizing the beneficial outcome (pain relief) and minimizing the risk of complications like infection or recurrent pain. Combining physical therapy and other physical activity, nutrition and sleep optimization, and education about recovery expectations yields a prehabilitation program that will speed up recovery. These programs are personalized, but each generally follows a typical pattern, as described in more detail during part 1 of our prehab article series.
- Physical therapy strengthens supportive muscles and teaches adaptive movement patterns to reduce pain and improve function. Other physical activity provides complementary anti-inflammatory/pain-relieving benefits while facilitating weight loss, lowering blood pressure, and improving diabetes to make surgery safer.
- Nutrition recommendations from a dietician/nutritionist build a meal plan that maximizes protein for exercise and surgical recovery while controlling appetite, despite being in a caloric deficit. This helps promote weight loss without suffering through constant cravings.
- Sleep optimization may be as simple as reviewing good habits like minimizing artificial light in the evening, getting approximately 8 hours of sleep each night, and other activities to receive the restorative benefits of sleep. A great night’s sleep lowers pain, improves mood, and makes it easier to resist delicious junk food. However, for patients with sleep disorders like obstructive sleep apnea, this pre-surgical optimization period may involve meeting with a sleep specialist and undergoing specialized testing. The effort will pay off, as untreated sleep apnea increases the risk of potentially fatal complications during surgery, as well as stroke, heart attack, and diabetes afterward. Many people don’t realize how bad their sleep has been until they treat it and receive new “super powers” of improved concentration, memory, and willpower.
- Finally, a little education goes a long way. Research shows that simply understanding the surgery process and recovery period improves satisfaction with the outcomes.
Most of the concepts in these plans are things we know are good for us, i.e.: good sleep and vegetables don’t need clinical trials to prove they’re valuable. However, their exact benefits are synergistic when applied together, and revamping everything about how a person eats, sleeps, and behaves is difficult to coordinate without help, especially while in pain and under a time constraint. This is exactly why some surgical programs facilitate prehab with specific referrals to other specialists. Similarly, Physical Medicine & Rehabilitation physicians specializing in prehabilitation may be useful counsel and coordinators of this care. Even outside of the surgery preparation, these programs will also likely contribute to some recovery beforehand, providing early relief to bridge the remaining time before the ultimate benefit of surgery.
When treating patients with serious golf related injuries, I highlight the importance of a thorough prehab plan that helps reduce the possibility of reinjury after successful surgery. Getting hurt is bad enough. It’s critical to do everything possible to ensure a successful recovery, so you’re quickly back on the links enjoying the game you love.
Meet the Author:
Alexander Watson, MD
Founder, Admire Health
Dr. Watson (Alex), is the founder of Admire Medical and also serves as the Associate Medical Director of Encompass Health in Middletown, Delaware. Alex completed his residency training in Physical Medicine & Rehabilitation at the University of Pittsburgh Medical Center (UPMC) where he published multiple book chapters and articles on prehabilitation, back pain, obesity, and the continuum of care for cancer rehabilitation.
He is trained in both Physical Medicine & Rehabilitation (PM&R) and Obesity Medicine, one of a handful of such physicians in the country.
© Copyright 2023. All Rights Reserved.