Transcripts - Episode 12: Golf, Spine Health, And Preventing Back Pain

Corey: All right. Welcome back to the Birdie Board podcast. This is episode 12 and that is pretty exciting.

So I have been doing a lot of winter based golf episodes to try to just help people continue their golf training through the off season. A lot of us, and especially in the Northeast now, are not playing much golf, so it is a perfect time to really gain understanding on the different parts of golf.

So with that, I brought in Mike Carnuccio. He has his Doctor of Physical Therapy. He is going to talk today about golf and the spine. So welcome, Mike. I know the first thing you have on the agenda is just talking about the mechanics of the spine. Do you want to just bring us right into it?

Mike: Of course, yeah. I was going to. First off, it is a pleasure to be here. Thanks for having me on.

So yeah, I think initially, I am a big imagery guy, right? So I think it is good for everyone to imagine, first off, your spine as one structure, right? So our spine is the center of our body and ultimately what it does is it protects the spinal cord, which is what connects our brain to our extremities and allows us to use our extremities, right? So it is a beautiful, beautiful thing.

Ultimately, with the spine, we have 24 vertebrae, which are bones. We kind of look like a dinosaur when you look at a skeleton. And so a portion of those make up the neck. Seven of them make up the neck. Twelve make up what are called the thoracic spine in the middle, and five make up the low back, or what we call the lumbar spine, right?

And so the fascinating part with the spine, and what I would like to focus on today, really are the discs. So a lot of people have heard of discs. A lot of people say, "Oh, I have a bulged disc," or have heard of a bulged disc. And the discs are often the problem in our spines, but they are also the reason that our spines can do what they do.

Corey: Are the discs like bone too?

Mike: Good question. So no.

So there are a couple of analogies that we used. When I was in physical therapy school, they used the analogy of a jelly doughnut. And I am not a huge fan because a jelly doughnut is so fragile. It makes people think they are just going to like squirt out jelly, which would be a herniated disc. I think that, I do not like that analogy.

So the two that I will use are: one would be, I actually just thought of this myself. It is funny, I threw it at Gemini just to see what Gemini thought, and Gemini thought it was a really good analogy. So, a leathery hockey puck, because they are disc shaped, right? Kind of like a hockey puck. And their material is kind of like leather or a mix of leather and almost like metals would be, like metals were woven throughout the leather.

And so it is pretty durable, very durable, but flexible at the same time because they have a jelly like inside. And that flexibility is what allows us to bend forward, bend back, side bend, rotate. We have it in so many planes of motion, which is what allows us to swing a golf club, right? You can swing a club because you can side bend, rotate, all of these different things. At the end of the day, the primary motion is rotation.

And so the flexibility, durability, that combo is huge for the discs and allowing us to do those things.

The other analogy would be like a tire. It would be like if you had a tire that is kind of rubbery, but still has metal within it. And I think it is interesting to note, now they are doing, over the last 10 years, a lot of disc replacement surgeries.

And so they do these for a lot of athletes, and the material they use is a combination of a fiber material and a metal, like a fiber and a metal woven throughout that creates the disc.

Corey: Our actual discs, do they actually have metal in them, not literal metal but like iron and stuff like that? Or is that just more analogous?

Mike: Yeah, so currently they use this fibrous tissue, but it is not, no, like, I mean, because our body does not generate metal. It is not possible to generate metal.

Corey: I do not think I literally meant metal. I meant more so made up of like minerals and iron and things like that.

Mike: Yes, no, so yes, you are spot on with that.

And the reason they use the metals in the disc replacement is the worst thing that can happen is that a disc collapses or gives out, because then you are losing the protection of the spinal cord itself. And now you have a chance for major issues and, in the worst case, paralysis. And now you cannot use your extremities and you lose all function.

So protection of the spine, durability of the spine, has been the number one goal when it comes to surgeries. And then they kind of focus on, can we still move and do our general activities.

Corey: Yeah.

OK, so just to catch everyone up to speed, I should have started with this outline a little bit, but we are going to, we just finished kind of diving deep into the mechanics and more of the technical terms. And we are going to slowly back it off from there, talk about common injuries, then take it back to even closer with like, how does this relate to golf, and then we will finish up with some examples.

So we just finished up with the actual mechanics, more of the technical understanding. Now we are going to move into some of the common injuries that could happen with your spine.

Mike: Yeah.

So yeah, I mean, the one that most people should be generally aware of is a disc bulge, right? And so I wish, in our office, I have a skeleton and on the skeleton they actually show, you can see the discs coming down the spine and they show an analogy of the disc bulging.

And anyone could look this up. If you went to YouTube and just typed in "disc bulge" and you could say something like "cartoon replica of this happening" or "3D replica," something like that, it will show you. And it is pretty cool.

So the physical disc literally protrudes, right? So it will literally shift and protrude, kind of like if I want to take a jelly doughnut and start to push on that doughnut, it will start to give and move in a direction, if that makes sense.

So disc bulge would be the most common thing that happens. A herniation is when the jelly on the inside, so the inside we call the nucleus pulposus, the outside, the outer layer, we call the annulus fibrosus. It is when that pulposus pokes through and squirts literal liquid onto your nerve root, which would give you a shooting pain.

Corey: That sounds terrible.

Mike: This is where people will get "sciatica." The term sciatica gets used a lot. We call it radiculopathy. It is when you get these nerve symptoms that shoot. And it could come from your neck and shoot down your arm, it could come from your low back and shoot down your leg.

So yeah, disc bulge, disc herniation.

Corey: So is bulge and herniation, are they opposite? Is bulge coming out and herniation more going in, or is it not exactly?

Mike: So it is the same. A good thing to understand, and that is a good question, is a high majority of discs bulge toward the back, posteriorly. So if I am facing this way, the bulges go that way, which, guess what, that is where the spine is, right?

The spinal cord sits kind of in the back and the nerve roots come out from the back and then innervate down the leg. Well, when the bulges go back, that is where they go toward the nerve root.

Corey: So is it bulging, like, is it correct to say inward, like it is almost bulging inward, or just shifting?

Mike: It is a good question. I say it bulges backwards, just because that is literally the direction it goes. If I am standing here, the disc bulges that way, which is toward where the nerve roots are.

Corey: I see, I see, I see.

Mike: And again, anyone right now, if you look up a replica of a spine, you would see what I am talking about. The disc has to go backwards to then pinch or adhere onto a nerve root and give you those particular symptoms.

Corey: So that is in the case of a bulge, right?

Mike: That is in the case of a bulge. So a bulge can get bad enough that the space for the nerve root, right? Here is my space, and a nerve root is coming out from the spinal cord and it comes through the space. We call that the foraminal canal. And it goes down and then it goes and innervates the muscles.

That is how we have sensation. It is how we activate muscles and contract muscles. Well, when the bulge comes in, this is what it does: it closes the space. So now my space is that big.

Corey: So it is like squeezing a straw tight.

Mike: Yes. And so the analogy I will use then, it is not that the bulge often hits the nerve root. It is that it makes the space small enough that inflammation fills that space, puts pressure on the nerve root.

And it is kind of like a water bottle. If I took a water bottle and I kept filling it with water and water, I kept filling it, the pressure within that water bottle would increase to the point where whatever is inside of there will have an increased pressure on it. That is what happens to the nerve root.

And so you have to reduce inflammation to then get pressure off the nerve root. And that is primarily what we do in physical therapy. I often do not physically change where the disc is, but I help to reduce compression of the disc and I help to reduce inflammation on the nerve root, and ultimately to reduce pain and improve the function for people, if that makes sense.

Corey: Yeah, definitely does, definitely does.

Mike: So anything else you want to say is, yeah, the last injury would be you could actually compress a nerve root with a certain action. And we will get into that, specifically with Tiger Woods, who was compensating for an oblique injury.

And when he was going and swinging over and over and over again, he was lifting his shoulder early because of the pain from his oblique, and he ended up tweaking his neck aggressively multiple times. And I think he literally compressed his nerve root a couple of times, and that was giving him shooting pain and it took him out for a while there.

Corey: Wow.

So that was the last type of mechanism. So we have a deeper understanding, well, you have a deeper understanding, we have the Cliff Notes version of it.

And you talked about three common injuries, the disc bulge, the herniation and the pinched nerve. So let us relate it now back to golf and how this kind of base understanding can kind of help us at least understand maybe some golf injuries or something like that.

Mike: Yeah.

So I mean, first off, you have to understand that in golf, right, we are rotating at pretty fast paces. I mean, some of these swing speeds have really gotten crazy, right? I mean, sometimes when we play, the theme which is impacting our swing speed is that that is how we are getting distance.

Well, there is only so much of a swing speed that we can control with our muscles. So if anyone has watched Full Swing on Netflix, great show, they do a fantastic job. They will always show the behind the scenes of these pro golfers training and they are in the gym and they are doing a lot of rotational training, which they should be.

They are going to train their oblique muscles. They are going to train the rectus abdominis. They are going to train the transverse abdominis. Different muscle groups that are involved. Their hips are very involved as well, right?

And so they are training these muscles through controlled motion. But when you get fast enough and you get strong enough, eventually the force is going to go through the spine and affect those discs.

So, you know, we see guys like Bryson DeChambeau. We have these guys who are, I mean, they are driving the ball 400 plus yards consistently. And it is leading to advantages on the course. And even their approach shots, DeChambeau is insane with how far he can hit his nine iron.

And a lot of this is coming from swing speed. If you ever watch DeChambeau on his YouTube channel, he will actually, he got together with Tim Tebow and they were like working on getting that swing speed up over a span of like a hundred swings. But dude, I am watching it, I am like, your control is getting less and less and less and less. There is more and more and more force on your spine.

And therefore a higher chance to compress your nerve root, higher chance to compress the disc, aggravate older discs, worst case, herniate a disc.

Corey: Yeah.

So before we jump to specific examples, I am going to stick on this injury topic for a little bit, because these podcasts I am doing during the winter are all about just like building your knowledge.

So we have kind of talked about how these injuries can occur. What are some things that people could do to help prevent these, not only in the off season? So let us take it in two separate buckets.

So what can they do this off season, say between today and March, depending on where you are in the country? And then what could they do when the season starts and they shift from their off season training to how do I stay healthy during the season?

Mike: Yeah, great, great question.

So first off, my first word of advice would be, make rotation a regular part of your training, right? So when you are in the gym, when you are, and I am assuming everyone who is out there is doing something in the training room, or you should for your spine.

Corey: Even for injury prevention, just to stay healthy.

Mike: Yeah, yeah, yeah. So even just for injury prevention, right? So make rotation a regular part of your training.

What are examples? There are a million ways to do it. You can take a cable, that is common what people do, or you could take bands and you can do a rotational punch, right? You can do what we call a Pallof press, which is where you basically do a step out, a punch, and a step back in, and you do that over and over and over again, and you train your oblique muscles to control those movements.

Corey: OK. How is that helping your spine?

Mike: Yes, good question. So remember, the way I just explained it with swinging a golf club is, when you go to swing a club, the more engaged your muscles are as you go and rotate and do different things, the more control that the muscles take on, the more force the muscles take. The less force that the spine itself takes.

Corey: That makes sense.

Mike: Yeah.

Corey: Makes total sense.

Mike: So we want the forces to be taken through the muscles and less through the spine itself.

However, I would say part two is, you need your spine, and this is where mobility comes in. So we talk about aspects of, we want to have strength and motor control of the right muscle groups. We also want to have good mobility through your spine.

If you can only be rotating a certain degree, 45 degrees to the left, well, when you go to swing, you are going to hit that end range and blow through it. And then most of that force goes through the spine itself.

And so you are not going to have good rotational mobility. What is the classic one? Lay on the ground and do what we call an open book, OK? Lie on your side, rotate your upper body and get a good deep stretch into rotation, and then come back and do that again.

Now, Corey, I would break training up into two parts. One is the training that you do just in general, right, just day to day. Then there is the actual warm up, right? So people are always like, and we struggle with this in physical therapy, I will give people home exercises, but sometimes, for older adults, I give them a warm up to do in bed before they get out of bed, because getting out of bed is a problem for them, because that is where their pain kicks in.

So I say, you know, warm up in bed before you get out of bed. Well, this is like golf, right? You cannot just show up and just start cranking your driver. I think some form of routine is really, really important in injury prevention.

So whether that routine involves getting on the ground on your side and doing physical open books to start to warm up the spine, or as simple as, I am going to start with my smallest club, I am going to start with a sand wedge, and I am going to do some nice easy swings and I am going to just rotate, and I am going to do that repetitively, and then I am going to work up slowly.

Corey: Yeah. So you could really simplify it to slow, kind of like if you were going to go on a jog, right? You can warm up your jog by just lightly jogging at first. You do not go full sprint, right?

Mike: Exactly.

Corey: With golf, you can do the same. You can go out, start with, the dumb thing people do is they go out and they go to the driving range, grab their driver first and they are just rocking the ball. And then they wonder why their low back hurts. And it is like, well, you did not warm up at all.

Mike: Exactly.

Corey: You get away with it in your teens and twenties. Take your thirties and things change quickly.

Mike: Yes.

So I think it is important to have a regular routine of training your oblique muscles, rotational strengthening of those muscles, to take on the force of when you swing, and working on mobility as well.

And then I would say the warm up routine is very important.

Corey: So would you agree that during this off season, the main focus is to strengthen your obliques and the rotational muscles, and then the important takeaway once the season starts is, obviously if they can keep that up, continue. It does not hurt anything. But to make sure to have some sort of routine to warm up, even if it is 10, 15 minutes, just get something to activate those muscles so that you are not causing injury for yourself.

Mike: Yeah, yeah. And that would be the two steps I would give. In the off season, highlight a lot of training. When you hit golf season, highlight that warm up and take a lot of what you did in the training and make yourself that warm up routine.

Those, I mean, that is a simple plan. I think everyone should put those in practice. It would be very beneficial.

If there were one other muscle group I would include in addition to those oblique muscles, those would be the hips. And so our hip muscles, the main one that everyone is extremely weak in, they play a pretty big role.

And now the question is, what is happening in your hips while you rotate your hips? So you want to have good internal rotation and external rotation ability at both of your hip joints, because this is a common rule in the body.

When you do not have good motion at one body part, at one joint, OK, so let us say your hip, you will compensate at the closest joint to get that motion.

So here is a classic example. I go to rotate to start my swing. When I go to rotate onto my back leg, I am internally rotating on my right hip. If I do not have enough internal rotation at my right hip, where am I going to compensate? At my spine.

My spine has to compensate for that lack of motion. I will then extra rotate at my spine, putting undue stress through the spine and therefore putting discs, because I really think they are at risk, at risk of a bulge.

Corey: I am glad you mentioned that, because I would not want someone listening to this to just think like, "Oh, the only thing I need to do is just strengthen my rotation and I am going to be a PGA golfer."

Because then, like you said, you could go the opposite way too. Now your spine is all strong, your rotation from your hips up is all really strong, but now you are putting extra strain on your hips, and now you are having a different problem. And you are like, "Mike and Corey, what the heck? I followed the plan."

So it is important to have a nice balance, but also really touch the major muscles in the golf swing, all of them, not just one.

Mike: So that is where again, yeah, I would say if someone was like, "OK, give me a quick three. What should I prioritize when I am training in preparation?" It would be the spinal rotation, right, and that includes mobility and activation of those oblique muscles, and then it would be hip rotational mobility, right, that is internal and external, and strength of those muscles. We have muscles that do those activities as well.

That would be the primary focus of what I would tell people to do.

Corey: Awesome. So what are some examples that you have seen among PGA golfers with these?

Mike: Yeah. So there were a few I wanted to bring up. And the one I actually like the most, that I remember watching on TV when it happened, was Will Zalatoris. So everyone remembers, right, short blond hair guy, real skinny, had a very powerful swing.

He is still playing and he is still on tour, but he is not the same, let us be real. In one year, he was second place at two different majors, two of the majors, and he was top 10 at the other two. So he was, at points, he looked like he was just going to be the next big name.

Corey: Yes.

Mike: And a lot of guys do that, right, they spring up. But I really do think he was impacted by his injury. So August 2022, we are going back three years now, at the BMW Championship, he later had an MRI that confirmed two bulged discs.

And I knew when I was watching on TV, at that time I am treating as a physical therapist. I watch him swing, I see what happens, I go, he has bulged discs, 100 percent. And the irony was he had a guy there with him, I do not know if he was a buddy, and that guy is like, "Oh," and the guy did a manipulation on him.

And I was literally covering my eyes like, no, bro. Because when you do a manipulation on the side of the bulge, you just compressed the disc more.

So the moment the guy did the manipulation, I was like, he is going to feel terrible. And he goes to walk and literally cannot move at that point. Like it was already flared and it got significantly worse.

I would have said, "Yo, take an anti inflammatory and just do some general mobility, and you are probably done because your swing is too aggressive."

So I did look up, and he ended up trying to rehab it himself without getting anything done and he was unable to. I think when you have a strong enough swing, a powerful enough swing, it is just too much on those discs.

And so what he had was called a microdiscectomy. And so if that disc bulges toward the back, they go in and they shave down a portion of that disc to open up space for that nerve.

Corey: That is terrible.

Mike: It is terrible. I mean, any surgery is rough on the spine. I do not advise ever getting surgery on your spine. However, if there was a surgery that is not very invasive, it is this one.

It is shaving down the disc. Way better than a fusion, which I will not even get into. But he had that done and then was able to rehab it slowly and get back.

But here is the reality for you with Will now. People, this is the issue with how people view injury. They think, "Oh, he had the surgery, he is good." That is not how it works. There is a toll that surgery takes on you.

So now his disc, which bulged, has had a portion carved off of it. You have a portion of the disc left now, it is still going, a lot of it, but if he bulges that disc again and has to get another discectomy on it, that space for that disc is not good anymore, because a lot of that jelly might have herniated out. And so the disc is losing a lot of height, and so that canal there for that nerve is getting less and less and less.

Corey: That is awful.

Mike: Yeah. Will Zalatoris could be looking at a disc replacement at some point in the future. Hopefully he does not do a fusion, because they are a nightmare in most cases.

But you know, his career is, I think, heavily impacted by the injury, and I really think he is going to deal with spinal issues the rest of his life.

Corey: Do you want to touch real quick, like in one minute, on what a fusion is?

Mike: Yeah. So fusions are the surgery right now that still should not exist anymore, but they do. They basically take the disc out and they put bone. So they will replace it with bone.

This is still done a lot. I see a lot of patients with it. Outcomes are completely mixed. About a third of people get better, a third of people stay the same, and a third of people get worse. The people who get worse, it is bad, it is really bad.

The people who get better end up having issues down the road, and here is why. When you replace a disc with bone, that segment does not move anymore. So that segment is now immobile. And so when you go to rotate and bend and side bend, you compensate at the segments above and below where the other discs are.

So now they take on a lot of the forces. You end up needing to fuse those segments. So most people I see will start by fusing the lower lumbar spine, because that is where most of our issues tend to be, L5 S1, L4 L5. But eventually they have to work their way up, L3 L4, L2 L3.

Soon they cannot even rotate. And then, well, then they just fuse the whole lumbar spine. In fact, I have had these where they go see a neurosurgeon and the neurosurgeon is like, "Look, I can fuse one segment or two. You will be back in a year or two. Let me just fuse the whole thing."

Corey: It seems like a propagating problem. Once you get one, it is just going to cause the rest to start to fail.

Mike: Yes, yeah. So I highly encourage people, do not go get a fusion. I really think that the disc replacements are promising.

We can get into it if you want to, but Tiger Woods just got one. That is his most recent, an actual replacement. And I highly encourage people to focus on, I said this earlier, the problem in most cases is that the space is small and inflammation is filling it.

If we can reduce inflammation, we can then improve your ability to keep up with a lot of activities and not have to get the surgery.

And we have a lot of things within our control that impact inflammation: stress, diet, sleep, and hydration. So these are the things I start to get into with people to address the inflammation, in addition to the therapy, the exercise, the mobility, to try to really hit that inflammation, get it down, and get them back to doing what they want to do without needing to get surgery.

Corey: Did you have any closing thoughts you want to leave us with?

Mike: Yeah. So I mean, I would say for those of you who are dealing with low back pain in relation to specifically golf, you might feel like, "Look, when I play golf, my back hurts. It feels like I cannot win. It feels like I am going to have to get surgery if I want to continue to play golf."

My personal story is that I dealt with my own back pain and my own disc bulge at L4 L5 left side at one point. Years ago I had shooting pain down my left leg. Well, I rehabbed it myself.

And so my encouragement would be, patience is key. You have to give yourself time. Discs have very poor blood supply and they take a long time to heal. And so really, if you are dealing with a low back pain injury, give that disc time.

Focus on ways to reduce inflammation. So focus on your diet, specifically sugar and processed foods and trying to reduce consumption of those. Focus on your stress and getting good levels of sleep. And you are going to see over time your inflammation is going to come down and your tolerance for rotation and swinging the club is going to get better.

And then of course, we already talked about it. Make your warm up and make your training a key part of what you do, and you are going to get back out on the course. I think you will get back to swinging pain free. Eventually, it is going to take time.

Corey: Yeah. I will say, I think I am sure this is an aspect of it too, one of the best improvements I made to my own golf game this year was actually watching you swing.

And it is not because you are a good golfer at all, so I do not want you to get too in your head at all.

Mike: I am actually very average at golf. I am not that good.

Corey: But your posture was so good. And I noticed it mostly in the straightness of your back. And I switched to that sort of posture, just not as hunched over.

And it is not like I was leaning over the ball, but I was a lot more relaxed with it. What it got me into is like an athletic stance, and I was rotating so much more clean and so much more consistent from that.

And honestly, I do not typically have any back problems or anything, but I just did not feel sore ever in my back. Just having the proper stance helped too.

So anyways, hopefully everyone enjoyed this episode of the Birdie Board podcast. There were definitely some technical pieces, but I love that background, especially during this winter golf phase. You guys can take it and Google more and ChatGPT, Gemini, whatever your AI tool is.

But Mike, thanks for joining us. And that is it for this episode of the Birdie Board podcast.

Mike: Oh yeah, baby. Get out on the sim, boys. Get out on the sim.