When performing the TPI screen on my golfers, the one test that seems to always get a "You want me to do what look?" is the single leg balance test. Once I explain what the test is measuring and how it impacts their golf game, all of my golfers understand the significance, but the reaction is generally the same.
Balance is such an overlooked part of a comprehensive golf assessment.
Instinctively we know balance is important, yet how often do we practice it? When we are injured, we train our muscles to get stronger and our joints to become more mobile yet we often neglect our balance system.
Perhaps balance seems so basic to most people or they don't quite understand how it works. Or maybe people assume if you train the other parts of the body, balance automatically improves as well. The truth is much more complex than that and in this post I want to shed some light on this complex yet fascinating topic.
The Three Systems
When we think of the term 'balance,' it is important we establish a definition to fully understand the concept. According to Physiopedia, balance "refers to an individuals ability to maintain their line of gravity within their base of support." To put it in layman's terms, balance allows us stay on our feet even if knocked off or outside our base of support. In order to do this, our body uses three primary systems.
The balance system and the brain are intimately connected.
As I get into it more shortly, two systems are directly in our head and the other system sends signals to the brain for input. I point this out because maintaining balance is a complex phenomenon most of us do without thinking twice about it. However, once the system begins to breakdown it is important to know how to get it back.
1. Vision
The primary and by far most dominant of the three is our vision. Without diving too in-depth into anatomy, it is important to understand how the eyes function in a basic sense. In our eyes, we have a thin layer lining the back of the eye called the retina. Within the retina are cells called photoreceptors that changes light into energy and sends the signal to our brains. These photoreceptors are separated into two categories, rods and cones. Rods enable us to see black and white and allow us to see in low lighting settings (night vision). Cones enable us to perceive colors and provide central vision.
As we begin to age (even in our late 20's!), our rods density begins to decline. By the time we hit 60+, the rod density is much sparser, leaving us with poor night vision (Sanders). If you think of older adults who suffer from falls, most occur late at night when lighting is not as good or getting up in the middle of the night to go to the bathroom. Add to the fact most older adults have some sort of visual impairment and we can see why falls occur more often (just one of the reasons why).
When we lose or have impaired vision our body has to use the other primary systems for balance.
Vision has been thought of to be the most dominant sense we use on a daily basis. It certainly has been the most researched (Hutmacher). In the game of golf, we painstakingly use our eyes to judge distances, wind, greens, etc. If our eyes are not providing us the correct information on the course, you can bet it can be impacting your score. Visual acuity is an underrated aspect of our golf game but might make the difference of 2-3 strokes per round.
2. Inner Ear
A second system in our bodies that contribute to maintaining proper balance is our inner ear system, or vestibular system. Our eyes and inner ears are intimately connected with one another due to the connections they have with our brains.
Within our inner ear, we have what are called semicircular canals. Think of these as narrow tubes that are situated in such a way as to reflect the different planes of movement we do daily such as looking left to right, up and down, and circular. Within these canals are contained fluid, called endolymph. When we move our head in a certain direction, this fluid moves as well. As this fluid is moving, it will pass into another chamber in the canal called ampulla. The ampulla is important because it contains hair cells that are sensitive to movement. If there is enough head movement, these hair cells will get activated to the point of sending a signal to our brain telling our brain what type of head movement is being performed.
Now, it bears mentioning some special organs in the inner ear that detect linear acceleration, gravitational forces, and head tilting. Within this vestibular labyrinth we have two organs, the utricle and saccule (don't you love these names?). The utricle is responsible for detecting movement in the horizontal plane (side-to-side) and the saccule senses vertical plane (up/down) movement. The process is similar as mentioned above in the semicircular canals with fluid and hair cells. However, these guys have an extra layer that contain crystals called otoconia, which are made up of calcium carbonate for those who want to know, and are heavier than the hair cells mentioned.
When your body experiences linear acceleration or a head tilt, these crystals will move and trigger the hair cells to fire to send a signal to the brain telling the brain what is going on (Know Your Brain).
3. Proprioception
The third and final system involves our nervous system and these awesome little guys are called proprioceptors. To know exactly what these receptors do, try this quick action. Take your hand and place it behind your back. Do you know your hand is behind your back or do you actually have to look at yourself doing it to know? Hopefully for all of us, you didn't need your vision telling you what you just did. The reason is because of the proprioceptors that are situated all throughout your body.
Think of these receptors as your internal GPS system. Just as we have receptors that fire signals to our brain for things like temperature and pressure, we have these receptors that tell our brain what are joints and muscles are doing all the time.
If you have ever sprained an ankle (guilty) you have most likely experienced the effects of an impaired proprioception system without realizing it. Even as you regain your strength, mobility, and endurance back into your ankle, you might still feel slightly "off" or not as steady as you thought you would. That is because you did not train your proprioception system. When I was a high school athlete playing basketball, my father, who is also a physical therapist, would always tell me to do my balance exercises or I would get injured again. Being a high school athlete, I naturally did not heed this advice. Sure enough, a couple months later I was nursing another sprained ankle.
This is typically the last part trained in a rehab program as you want to allow the body proper healing time to reduce swelling and regain strength and flexibility. However, just because it usually is last does not diminish the importance this system has on the rehabilitative process.
Connecting the Dots
Now that you know the three systems, how do they all connect? And how do you determine if you have an issue with one of these? Both are great questions, and I will explain next.
As I mentioned earlier, the eyes and inner ear are intimately connected due to the direct access each has with the brain. This is most dominantly seen via the vestibulo-ocular (VOR) reflex (see image below for how VOR works as well). To understand this, I want you to do another experiment. Looking straight ahead at your computer screen, focus on something specific. Now, turn your head to your right but keep your eyes fixated on the specific point you are focusing on. When you turn your head to the right, your inner ear tells your brain "Hey, we are turning our head to the right." This signal triggers the brainstem to activate the muscles in our eyes to counter-rotate to the left to keep your eyes fixated straight ahead. Pretty cool, huh?
Our proprioceptors work by essentially filling in the gaps of what our eyes cannot tell us.
For example, when you go to swing the club, your eyes are fixated on the ball. The rest of your body is working hard by sending signals from your proprioceptors in your feet, hands, and rest of your body. This way, your eyes can stay focused on the objective of this great game, which is to hit the ball without having to worry about looking at your hands and legs to make sure they are in the proper position to swing the club.
All of this information is processed practically instantly.. These three systems must be working in unison constantly to help keep us upright and to maintain our base-of-support when performing our daily activities.
Self-Assessment
Knowing the balance systems is great, but how can you assess yourself to see if you have any balance issues? It is actually easier than you think and these videos show how. With all these tests, you always start with your eyes open first then see if you can perform the same movement with your eyes closed.
***Quick side note, I always encourage people to perform these assessments in a corner in case you lose your balance and cannot catch yourself. I am a physical therapist, so safety is always on my mind!
1. Romberg Stance
Let's start with the easy one. Simply bring your feet together and try to balance. To make this harder, try to cross your arms across your chest. Want to make it even harder? Close your eyes. Try to hold each position for 30 seconds. If you pass, you can move on to #2.
2. Sharpened Romberg Stance
Now, you are going to place one foot in front of the other, trying to touch your heel of your front leg to the toes of your back leg. Again, cross your arms across your chest for increased difficulty and end with closing your eyes for the most difficult. You must be able to perform for 30 seconds with each leg as the lead foot before moving on to #3.
3. Single Limb Stance
Finally, this brings us to the test I use on all my golfers when performing the TPI golf assessment. Simply lift one leg off the ground and bring the lifted hip to 90 degrees. Hold position for 30 seconds. Repeat on opposite leg. As always, try to close your eyes and see if you can hold for 30 seconds as well.
These three stances with slight variations give me a general sense of where your balance weaknesses are and where I can start planning a treatment plan for you. With each of these, we can make it even more specific by having you stand on some sort of foam pad or pillow which will give me even more information as far as which balance system to start training first. But, these exercises are a great beginning to see if your balance may be effecting your golf swing.
Conclusion:
Balance is an underrated part of our golf game.
While most fitness programs focus on strength and flexibility, it is important you do not neglect your balance systems as a golfer. Although most swing faults such as sway and slide can be attributed to muscular dysfunction, an impaired balance system may be the missing link in your game.
Make sure you grab my free Low Back Pain eBook here and follow me on all my social media platforms.
Until next time golfers,
Dr. James Caldwell, PT, DPT
References:
1. Hutmacher, Fabian. "Why Is There So Much More Research on Vision Than on Any Other Sensory Modality?" Frontiers in Psychology. 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787282/.
2. "Know Your Brain: Vestibular System." 11/15/15. https://www.neuroscientificallychallenged.com/blog/know-your-brain-vestibular-system.
3. Sanders, Laura. "Twilight of the Eye." Knowable Magazine. 2/28/20. https://www.knowablemagazine.org/article/health-disease/2018/twilight-eye.
Pictures used with permission:
1. "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work
2. Simple Vestibulo-ocular reflex By Mikael Häggström, used with permission.