Inside This Issue

• Greetings from Jim Mclean
• Spotlight of founding Members
  
• Dr. Rosen´s Review of: “Medal and Lateral Epicondylitis (GOLFER´S AND TENNIS ELBOW)"
  
• Dr. Rosen´s review of: Injuries and Overuse Syndromes in Golf
  
• Russ Paine´s Repair of Rotator Cuff Tears in Golfers (From a Physical Therapy Perspective)
  
• The Third annual Jim Mclean Invitational
  
• Schedule of this Year´s Tournament
  
• Highlights of Last Year´s Tournament

Greetings from Jim Mclean

I would like to thank all the members and friends who are participating in the 2009 Jim McLean Invitational at Quaker Ridge. As a founding member of the Society, it’s been a pleasure to see the foundation grow through the past few years and we look forward to a bright future! It’s great to see a charity that is so focused on helping underprivileged youth to learn the values that the game of golf has to offer. With your continued support, the Society will be able to reach many children and continue their success in learning the game of golf.

I hope everyone had an excellent summer golf season and thanks again!

JIM MCLEAN
Jim McLean Enterprises, Inc.

Spotlight of founding Members

Dr. Rosen is the Chairman of the Department of Orthopaedic and Rehabilitation at New York Hospital Queens, and Attending Physician at New York Hospital Queens. He is an Associate Professor of Clinical Orthopaedic Surgery at Weill Medical College of Cornell University, Clinical Professor at NYU School of Medicine, Attending Physician at the Department of Orthopeadic Surgery NYU Hospital for Joint Diseases, NYU School ofMedicine, and Bellevue Hospital Center.

Dr. Rosen treats injuries and conditions involving the shoulder, knee, and elbow. He specializes in arthritis, arthroscopic surgery, rehabilitation, sports medicine, and adolescent sports medicine.

Dr. Rosen received his medical degree from Columbia University College of Physicians and Surgeons and completed his orthopaedic residency at NYU Hospital for Joint Diseases and fellowship from the prestigious Kerlan-Jobe Orthopaedic Clinic in Los Angeles, California.

Dr. Rosen is the author of over 30 publications and presents regularly at local, national, and international scientific meetings.

Dr. Rosen is a member of the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine and Founding Member of the Society for Golf Medicine and Performance.

Dr. Rosen has served as Physician Attendant at:

• U.S. Open Tennis Tournament, 1993-1996
• Alvin Ailey Dance Theater, 1994-1996
• N.Y. City High School Football - PSAL, 1993-Present

Past Affiliations

• Assistant Team Physician/Orthopaedic Consultant:
• Los Angeles Dodgers 1998,1999
• Los Angeles Lakers 1998,1999
• Los Angeles Galaxy 1998,1999
• Los Angeles Kings 1998,1999
• Los Angeles Sparks 1998,1999
• Anaheim Angels 1998,1999
• Anaheim Ducks 1998,1999
• University of Southern California Football Team 1998,1999
• Loyola Marymount University Sports Teams 1998,1999
• Orthopaedic Consultant - De La Guarda Dance Company
• Team Physician/Orthopaedic Consultant for the Brooklyn Cyclones - Class A affiliate of the New York Mets: 2001-2005
• Team Physician for Queens College

Dr. Rosen will be honored by the New York Chapter of the Arthritis Foundation on October 22nd, for his dedication and commitment to the community. He will be the recipient of the Queen’s Physician Leadership Award.

Russ Paine, PT is currently Director of Rehabilitation and Research Memorial Hermann Sportsmedicine Institute in Houston Texas. He is also the Team Physical Therapist for the Houston Rockets and has been involved in sportsmedicine rehabilitation in the Houston area since moving to Houston in 1991. Russ has been a rehabilitation consultant to NASA and the Houston Astros.

Originally from Lubbock Texas, Russ is an avid golfer with a 5 handicap and has worked with golfer's of all ages and abilities. Steve Elkington, Mark O’Meara, Scotty McCarron are a few of the recent PGA tour golfers that Paine has helped recover from injuries. Russ has published and lectured on many sportsmedicine topics including golf injuries and performance in his 27 years as a sports physical therapist and a founding member of both the ICCUS and The Society for Golf Medicine and Performance.

DR. ROSEN’S REVIEW OF:
"Treatment of Medial and Lateral Epicondylitis – Tennis and Golfer’s Elbow – with Low Level Laser Therapy: A Multicenter Double Blind, Placebo-Controlled Clinical Study on 324 Patients"

JOURNAL:
Journal of Clinical Laser Medicine & Surgery, 1998

AUTHORS:
Zlatko Simunovic, MD; Tatjana Trobonjaca, MD; and Zlatko Trobonjaca, MD

ABSTRACT:

BACKGROUND AND OBJECTIVE: Among the other treatment modalities of medial and lateral epicondylitis, low level laser therapy (LLLT) has been promoted as a highly successful method. The aim of this clinical study was to assess the efficacy of LLLT using trigger points (TPs) and scanner application techniques under placebo-controlled conditions.

STUDY DESIGN/MATERIAL AND METHODS: The current clinical study was completed at two Laser Centers (Locarno, Switzerland and Opatija, Croatia)as a double-blind, placebo controlled, crossover clinical study. The patient population (n = 324), with either medial epicondylitis (Golfer's elbow; n = 50) or lateral epicondylitis (Tennis elbow; n = 274), was recruited. Unilateral cases of either type of epicondylitis (n = 283) were randomly allocated to one of three treatment groups according to the LLLT technique applied: (1) Trigger points; (2) Scanner; (3) Combination Treatment (i.e., TPs and scanner technique). Bilateral cases of either type of epicondylitis (n = 41) were subject to crossover, placebo-controlled conditions. Laser devices used to perform these treatments were infrared (IR) diode laser (GaAlAs) 830 nm continuous wave for treatment of TPs and HeNe 632.8 nm combined with IR diode laser 904 nm, pulsed wave for scanner technique. Energy doses were equally controlled and measured in Joules/cm2 either during TPs or scanner technique sessions in all groups of patients.The treatment outcome (pain relief and functional ability) was observed and measured according to the following methods: (1) short form of McGill's Pain Questionnaire (SF-MPQ); (2) visual analogue scales (VAS); (3) verbal rating scales (VRS); (4) patient's pain diary; and (5) hand dynamometer.

RESULTS: Total relief of the pain with consequently improved functional ability was achieved in 82% of acute and 66% of chronic cases, all of which were treated by combination of TPs and scanner technique. Conclusions: This clinical study has demonstrated that the best results are obtained using combination treatment (i.e., TPs and scanner technique). Good results are obtained from adequate treatment technique correctly applied, individual energy doses, adequate medical education, clinical experience, and correct approach of laser therapists. We observed that under- and overirradiation dosage can result in the absence of positive therapy effects or even opposite, negative (e.g., inhibitory) effects. The current clinical study provides further evidence of the efficacy of LLLT in the management of lateral and medial epicondylitis.

PURPOSE OF ARTICLE:To Assess the efficacy of low level laser therapy using trigger points and scanner application techniques under placebo-controlled conditions.

TYPES OF INJURY DISCUSSED: Medial and lateral epicondylitis (golfer’sand tennis elbow).

METHODS: Prospective randomized study at two Laser Centers (Locarno, Switzerland and Opatija, Croatia) as a double-blind, placebo controlled, crossover clinical study. The patient population (n = 324), with either medial epicondylitis (Golfer's elbow; n = 50) or lateral epicondylitis (Tennis elbow; n =274). Patients were treated with Trigger Point Technique, Scanner Technique, or combination tehnique.

RESULTS: Statistically significant results were found for: differences between acute and chronic cases treated with scanner versus combination technique -with acute cases responding significantly better to combination therapy. Therapy demonstrated decreases in pain and improvement in functional ability.

CONCLUSION: Positive treatment effects (pain relief and restored functionalability) depend on exactly determined, adequate and optimal, individual energy doses applied on Trigger Points of the affected tissue. The combination of triggerpoints and scanner technique was the most successful therapeutic procedure in this research, although there was no significant difference in comparison to results achieved with trigger point technique alone. Therapy should be conducted gradually and regularly; interruption between two treatments should be less than one week. The chronicity of a patient’s condition can influence therapy results with acute cases achieving significantly better results. The efficacy of low level lasers applied as monotherapy in the current study indicated positive clinical effect in pain relief and functional ability of medial and lateral epicondylitis.

REVIEWER'S COMMENTS: This is a prospective randomized double blind, placebo controlled, crossover clinical study performed at two separate laser centers.The article provides a good review of the possible beneficial effects of low level laser therapy. Treatment with combination therapy (trigger point and scannertechniques) applied gradually and regularly appears to offer the best results and cases appear to respond better than chronic cases. Treatment resulted in pain relief and restored functional ability. Treatment appears to depend on specific technique and exactly determined/optimized applied energy doses which may correlate with provider technique and experience.

Jeffrey E. Rosen, MD
Chairman, Department of Orthopaedic Surgery and Rehabilitation Medicine, NewYork Hospital Queens Associate Professor of Clinical Orthopaedic Surgery,Weill Medical College of Cornell University

DR. ROSEN’S REVIEW OF: Injuries and Overuse Syndromes in Golf

JOURNAL:
The American Journal of Sports Medicine, 1998

AUTHORS:
Georg Gosheger,MD, Dennis Liem, Karl Ludwig,MD, Oliver Greshake,MD and Winfried Winkelmann, MD

ABSTRACT:

BACKGROUND: Although golf is becoming more popular, there is a lack of reliable epidemiologic data on golf injuries and overuse syndromes, especially regarding their severity.

OBJECTIVE: To perform an epidemiologic study of the variety of different musculoskeletal problems in professional and amateur golfers and to find associations of age, sex, physical stature (body mass index), warm-up routine, and playing level with the occurrence of reported injuries.

STUDY DESIGN: Retrospective cohort study.

METHODS: We analyzed the injury data from a total of 703 golfers who were randomly selected over two golfing seasons and interviewed with the use of a six-page questionnaire.

RESULTS: Overall, 82.6% (N = 526) of reported injuries involved overuse and 17.4% (N = 111) were single trauma events. Professional golfers were injured more often, typically in the back, wrist, and shoulder. Amateurs reported many elbow, back, and shoulder injuries. Severity of reported injuries was minor in 51.5%, moderate in 26.8%, and major in 21.7% of cases. Carrying one’s bag proved to be hazardous to the lower back, shoulder, and ankle. Warm-up routines were found to have a positive effect if they were at least 10 minutes long.

CONCLUSIONS: Overall, golf may be considered a rather benign activity, if overuse can be avoided. If not, golf can result in serious, chronic musculoskeletal problems.

REVIEWER'S COMMENTS: This is a retrospective cohort study performed to gather epidemiologic data on golf injuries and overuse syndromes related to the sport of golf. It was performed by analyzing data obtained from a 6 page interview questionnaire distributed to 703 randomly selected golfers of varying ages abilities. The majority of injuries reported fall into the category of overuse injuries rather than acute traumatic injuries (82.6% versus 17.4%).
The majority of injuries are of minor severity and professionals are injured more often than amateurs. Carrying a bag appears to have a negative impact while stretching, which must be at least 10 minutes long appears to have a positive impact.

The limitations of the study are inherent in the design being a questionnaire survey with self report results which must be considered subjective and associated with recall bias.

Jeffrey E. Rosen, MD
Chairman, Department of Orthopaedic Surgery and Rehabilitation Medicine, NewYork Hospital Queens Associate Professor of Clinical Orthopaedic Surgery,Weill Medical College of Cornell University

RUSS PAINE, A PHYSICAL THERAPIST’S REVIEW OF: Repair of Rotator Cuff Tears in Golfer

Michael J. Vives,M.D., Lawrence S.Miller,M.D., David L. Rubenstein,
M.D., Rajiv v. Taliwal, M.D., and Carl E. Becker, M.D.

Arthroscopy: The Journal of Arthroscopic and Related Surger, Vol 17, No. 2, 2001, pp 165-172

Many executives dream of the day that they are able to spend their hard earned retirement time on the links. Unfortunately for some, aspirations of golfing 2-3x per week may be disrupted from a rotator cuff injury.
This article describes outcomes of golfer’s that have sustained rotator cuff tears and gone on to undergo repairs. As you can imagine, this patient population will be very motivated, which probably has an effect on resultant outcome.

Unlike other sports, golf allows even “super seniors” to be competitive.As a result of aging, rotator cuff tears may creep into the myriad of injuries that present with aging golfers. Although debilitating and painful, this article will describe outcomes that show that rotator cuff repair allows most golfers to return to the sport. Strengthening and rehabilitation techniques as well as swing changes will be discussed.

What is the function of the rotator cuff during golf? That depends on the type of swing utilized. A swing that keeps the elbows somewhat tucked to the body will have minimal firing of the rotator cuff. Swings that take the club in a more “outside to in” swing will require more rotator cuff firing, as the arms are more away from the body. Most professional golfers generate club head speed using the “big” muscles of the trunk and core. A good analogy is a spinning figure skater. As the skater begins to accelerate the spinning near the end of a routine, they bring the arms in to the body, allowing more centripetal acceleration to occur. The closer the arms are tucked to the center of rotation, there is a decrease in the moment of inertia and thus less demand on the rotator cuff to provide acceleration of the trunk. This will have implications as we discuss return to golf after rotator cuff repair.

This study reviewed results in 29 golfers that underwent rotator cuff repair. Average age was 60 years, 25 men and 4 women. Most of the patients had gradual onset of symptoms (20 patients). The lead shoulder was involved in 16 shoulders and the trailing shoulder involved in 15 shoulders with 2 patients having bi-lateral involvement. The average duration of symptoms was 10 months, and none of the patients were able to play golf when it was decided to pursue surgical treatment.Twelve shoulders underwent open acromiplasty and cuff repair, and sixteen shoulders underwent mini-open rotator cuff repairs. All RC repairs were able to be mobilized and repired tendon-to-bone in the anatomic position. All tears were found to be full-thickness tears.

Active motion was begun at 4-6 weeks and resistance exercises generally started at 10-12 weeks. Chipping and putting was allowed at 3 months and driving 4 to 5 months. All patients reported being satisfied at followup. The average number of rounds per week before symptoms was 2.2 with a slight decrease in post-operative rounds per week to 2.0. There was no significant difference in presymptomatic handicap at follow-up (17.5 preop and 19.1 post-op). There was also no significant difference in mean drive distance although there was a mean decrease from 212.4 to 208.7 yards.

Takeaway was the most commonly reported phase of the golf swing that was associated with symptoms. Lead or trailing shoulder involvement was found to be insignificant with respect to driving distance and handicap scores.

Cuff tear size and golf performance were correlated. Twenty patients had medium size tears 17 having good results. There were 4 good and 1 satisfactory results among 5 patients with large tears, and 2 patients with massive tears did not have good results. One of the massive tear patients re-injured during MVA, and the other had satisfactory results with a decrease in performance of 10 stroke handicap increase and 25 yard decrease in distance. This patient was still able to play without pain.

Ninety percent of these patients were able to resume golf, with 88% able to return to their competitive level. This is a high percentage of favorable results and the authors believe that there were several factors at work to create this outcome. First, the golfers were highly motivated to conform to the rigors of post-operative rehabilitation and compliance. Second, the golf swing is “easy” on the rotator cuff. This is probably due to the ability to keep the arms from ranging below 90 degrees, which is vastly different than the range of motion required to throw a baseball. The authors believe that takeaway phase may have caused more pain due to the elevation requirements during this phase of swinging.

Although lead versus trailing shoulder repairs showed no difference in this study, others (1,2) have reported lead shoulder involvement. EMG studies show greater activity in the rotator cuff of the lead shoulder during the golf swing, but that activity is very low in comparison to the “power muscles” of the upper quarter (3). The pectoralis major, latissimus dorsi, scapular muscles, and erector spinae were the most active muscles during the golf swing. It must be noted as previously mentioned that this study involved professional golfers with much more perfect mechanical swings. This reduces the need for rotator cuff involvement because the swing speed is generated by the larger muscles of the trunk. The myriad of swing techniques can be readily observed on a public driving range.
Most amateurs take the club back outside the swing plane which causes a more upward lifting of the club. It would make sense that this will be a more difficult swing for the rotator cuff involved golfer to assume. Most professional players involve trunk/core strengthening as a mainstay of their conditioning program. In my own clinical experience when advising competitive amateurs on a conditioning program, implementing a core strengthening program is the number one factor that increases driving distance in the young elite golfers.

When the cuff injured golfer is ready to resume swinging, there are a few things we believe are critical to preventing further injury.

1. Restoring full ROM: all planes of motion are important, but one of the most important motions to restore is cross body adduction.
   This well help alleviate internal impingement from occurring and allow the take-away phase of the golf swing to be unrestricted (lead shoulder). The “genie stretch” was described by us in Andrew’s The Athlete’s Shoulder second edition(4). This stretch constrains rotation and allows the stretch to be focused on the posterior cuff muscles. (see figure 1).
   
   
2. Restoring posterior cuff strength: External rotator cuff strength is the most inhibited of the cuff muscles and restoring this strength will help center the humeral head during the golf swing. We prefer a 45 degree angle using theraband to isolate the infraspinatus/teres minor. (see figure 2).
   
   
3. Keep the elbows tucked during the golf swing. At least initially during the recovery period, this golf posture will take the load off the rotator cuff. A good drill to practice this technique is to swing with golf tees or small towels tucked under the arm. The goal is to avoid dropping the tees during the swing. (see figure 3). This golf swing not only takes forces off the shoulder, but in most cases will improve accuracy as it promotes taking the club back on the proper swing plane.
   
   
4. Implement core strengthening. (see figure 4) Golf is a controlled fall. If your spine extensors and rotators were not firing at address, you would fall over. The trick of the effortless swings on the PGA tour is maintaining the spine angle. This allows optimum efficiency of the other moving parts. As swing velocity increases, the force required to maintain the clubhead within the swing plane circle doubles. So if you double your swing speed, you quadruple the centripetal force at the center of rotation – spine). This is one reason it so difficult to hit the ball solidly when swinging hard. Rotator cuff function is important in almost any sporting activity. Golfing is no exception. Although there is low rotator cuff activity in a professional golf swing, remember that 0 of 29 patients in this study were able to play golf with their rotator cuff dysfunction. The outlook for returning to golf after rotator cuff repair is very positive, although there may be a slight diminution in performance the golfer is able to resume the sport without significant pain. Motivation to fully comply with the post-operative regime was probably a big determinant in the positive outcome. Prevention of rotator cuff pathology was not discussed, but we know that as aging occurs, we lose the elastin content of the rotator cuff, making this muscle group stiffer, and more prone to tearing. It does make sense that maintenance of normal ROM and improving rotator cuff strength might be a factor in prevention of rotator cuff injuries.
   

Rotator cuff function is important in almost any sporting activity. Golfing is no exception. Although there is low rotator cuff activity in a professional golf swing, remember that 0 of 29 patients in this study were able to play golf with their rotator cuff dysfunction. The outlook for returning to golf after rotator cuff repair is very positive, although
there may be a slight diminution in performance the golfer is able to resume the sport without significant pain. Motivation to fully comply with the post-operative regime was probably a big determinant in the positive outcome. Prevention of rotator cuff pathology was not discussed, but we know that as aging occurs, we lose the elastin content of the rotator cuff, making this muscle group stiffer, and more prone to tearing. It does make sense that maintenance of normal ROM and improving rotator cuff strength might be a factor in prevention of rotator
cuff injuries.

REFERENCES:

1. Jobe FW, Pink MM. Shoulder pain in golf. Clin sports Med 1996:15:55-63

2. Meister I, Andrews JF. Classification and treatment of rotator cuff injuries in the overhead athlete. J Orthop Sports Phys Ther 1993:18:413-421.

3. Pink M. Jobe FW, Perr J. Electromyographic analysis of the sholder during the golf swing. Am J sports Med 1990;18:137-140

4. Andrews JA, Wilk KE, Reinold MM. The Athlete’s Shoulder 2nd edition, 2009.

FIGURES:

Figure 1. “Genie Stretch” This stretch is focused on stretching the posterior cuff muscles and can be helpful when golfer has pain taking the club back in the lead shoulder. Start with elbows crossed in front, lift involved elbow with opposite hand, then pull elbow across chest in a diagonal. Hold 10 seconds 10 reps. (good one to do in the shower)

Figure 3. Swing drill for rotator cuff patients returning to golf. Use golf tees, or towels tucked under both arms. The goal is to be able to complete the backswing and forward swing and not allow the tees to drop. This takes force from the rotator cuff during the swing is a great way for patients to resume the initial golf swing.

Keep legs straight and lift w/low back



Hands behind LB, extend torso, then curl chest over ball.
3 sets of 20 repetitions

The Third annual Jim Mclean Invitational

The tournament will be held on Tuesday, September 22nd, 2009 at Quaker Ridge Golf Club in Scarsdale, NY.
With 18-holes of championship golf, Quaker Ridge Golf Club will prove to be a challenge and a unique golfing experience to golfers of all skill levels.

We greatly appreciate the following golf courses for their consideration in offering complimentary services to a group of underserved high school students for the 2010 program:

DORAL GOLF CLUB
Miami, Fla

QUAKER RIDGE GOLF CLUB
Scarsdale, NY

SPRING CREEK GOLF CLUB
Hershey Park, PA

TOWER COUNTRY CLUB
Floral Park, NY

WHEATLEY HILLS GOLF COURSE
East Williston, NY

REGISTRATION INFORMATION
For more information contact us at www.societyforgolfmed.org or call 718.369.8041

HIGHLIGHTS OF LAST YEAR’S TOURNAMENT

Last year’s tournament was wonderful! Hope you can join us this year!

Jim McLean’s instructional clinic

Women’s Winner Circle