Golf Club of Tennessee Case Study: Knee pain and pull hooks

Apr 20

We recently had Nashville golfer come into the clinic after hearing about us from a friend. Alex was a devoted, life long golfer who plays most of his rounds at Golf Club of Tennessee. Unfortunately, Alex had been dealing with knee pain for the last 5 years in his lead side knee. The pain had started vaguely, on and off until it became more consistent the last few years. This year, to start the season, it immediately started bothering him in his swing and never let up. Let’s walk through what Alex has been experiencing, what Orthopedic doctors have recommended, and what eventually ended up working for Alex.

Knee pain and options for intervention

Alex had imaging on his knee 3 years ago. The MRI revealed some arthritic changes and a medial meniscus tear. The arthritic changes are relatively normal, and though meniscus tears can be a normal part of the aging process, it seemed like this was the pain generator in this case. In Alex’s previous consultations, he had been recommended injections to mask the pain for a year or two, and surgery to clean up the meniscus (variable results in the literature). Alex decided to hold off on the surgery and injections, but had not gotten help to rehab the meniscus. Finally, Alex was introduced to Integrated Rehab and Performance Center.

Knee pain and the pull hook

Alex had noticed his knee pain was severely impacting his game, especially at the start of this season. He could feel that he was not creating much force from the lower half and was creating a top half dominant swing. The result? Spinning out, sliding, and pull hooks. It was time to do something.

The physical exam and the body-swing connection

When we looked at Alex, we broke it down into 5 sections.

1. The SFMA global movement exam

This tells us more about how we move through multiple joints while weight bearing to accomplish a task.

2. The Titleist Performance Institute physical screen

This tell us more about how you use multiple joints to get into (or not) golf positions and control them.

3. Biomechanics

This is where we look at the each joint individually to see where your passive range of motion actually is. We are looking for true joint mobility.

4. Orthopedic and Special Testing

Here we create a better understanding around the diagnosis, test for painful movements, and assess where we need to start in the way we load and move through the knee.

5. Swing analysis

This is where we found the slide and spinning out characteristics in his swing. We use this data to relate back to his physical findings and see where physical limitations may be related to his swing characteristics. We know how his knee pain is directly related to his swing faults, but where else might he be struggling that is leading to these characteristics? The exam above will let us know…

The body-swing connection

This is what we found…

1. SFMA

a. Missing global rotation to both the left and the right.

b. Single leg balance limitations, especially on the left.

c. Right shoulder external rotation and abduction (away) restriction.

These limitations support that there is a rotation limitation(s) somewhere in the body limiting global positions of rotation, though we have not found the precise location yet. We also have a single leg balance issue which has many different causes, including a limitation in being able to shift weight into that side (hip and pelvis mechanics). Last, a right shoulder that does not fully achieve external rotation while abducted or reach away from the body will directly influence over the top and steep swing characteristics. With a closed club face, this can lead to pulled balls off the tee.

2. TPI

We found many important limitations, but here are the most pertinent to the body-swing connection.

a. Lower quarter rotation restrictions.

b. Shoulder 90/90 restrictions.

c. Single leg bridge restrictions.

d. Pelvic tilt and rotation motor control missing.

These findings support there is a major inhibition in the glute muscles as they do not contribute to control and stability at the pelvis. We also found that the limitations in global rotation or more of a lower half problem than a trunk rotation problem. Last, the shoulder 90/90 test showed us that his trail side shoulder would not achieve 90 degrees of rotation in standing and gets worse in golf posture, telling us a motor control problem exist at the shoulder complex as a whole.

3. Biomechanics

Again, we had a list of joints and regions that were limited in passive range of motion testing, but here are the highlights.

a. Hip internal rotation (left 13 degrees, right 22 degrees while 30+ is ideal)

b. Hip external rotation (R38 degrees while 45+ is ideal)

c. Shoulder external rotation (right 78 degrees while 90+ is ideal)

d. Shoulder adduction (L15 degrees while 45+ is ideal)

These findings now give us the details we were looking for. There are global movement restrictions in rotation and we noticed that Alex had struggled in multiple pelvis and motor control and mobility tests. We found that he actually has a true mobility limitation (among other findings) that would directly contribute to this issue. He also struggled to achieve shoulder positions that required external rotation which finally makes sense as we see he has access to less than 80 degrees of shoulder external rotation while 90+ is preferred for a smooth and efficient golf swing.

4. Orthopedic and special testing

a. Positive meniscus orthopedic testing.

b. Limitations in lower extremity motor control test with asymmetry between left and right (right worse).

c. Missing intra-abdominal pressure and bracing strategy.

This data highlighted here helps to confirm it is indeed a meniscus that is injured, informed us and gave us objective data around the ability to stabilize on one side of the lower extremity at a time (showing the right side was much worse), and told us it will be worthwhile to address central stabilization and stabilizing strategies.

5. Golf swing analysis

a. Slide

b. Over-the-top

c. Spinning out

d. Resulting pull hooks

These details found from two swing videos, a face on and a down the line view. We knew about the pull hooks when he came in and found the other characteristics from video. Now, how are all of these things related and how can we help him and his coach address these swing characteristics?

Putting it all together

There is a common link here… This golfer is missing hip mobility on his lead side leg, and it is creating chaos, injury, and poor performance. The 13 degrees of hip internal rotation is related to his re-emerging and now severe knee pain as well as his changing swing characteristics and poor performance. Here is how…

The lead side hip allows us to turn full on the backswing before becoming a major force generator and absorber in the downswing. We need this mobility here for the pelvis to turn into the stable hip without allowing excessive slide and lateral movement. As the hip loses mobility, the structures around it begin to take more of the load and demand. These are joints less desirable for this task! Often, it is the low back that throws in the towel first, but in this case, the lead side knee had a previous injury that resulted in re-injury and pain. Now to slow down our top speeds, the knee is experiencing more torque along with the ankle and foot. With or without a previous history of knee injury, this is a compensatory way to absorbs forces in the long term, resulting in Alex’s recurring and substantial knee pain.

Further, the hip mobility is directly related to his new swing characteristics and miss. As the lead side hip loses mobility and is limited in its ability to move and slow the swing down after impact, it will begin to share the forces around other joints or change the way the forces are created. In this case, the missing hip mobility limited him from turning into his lead side and creating a stable “wall” or “pillar” and instead the body let him drift out past the lead side resulting in the slide. This takes advantage of the muscles along the outside of the hip, using them as elastic brakes of lateral force. He also begin to spin out, keeping too much of his weight on his trail side and releasing tension from the lead side so the forces could dissipate in an open more relaxed chain then if he shifted and braced on the lead side. Additionally, his missing external rotation on the trail side is an important additional finding that is effectively and significantly limiting his ability to improve on these swing characteristics. It is exceptionally hard while missing external rotation to not create a steep swing path without being able to manipulate the swing path somewhere else. With his knee pain and mobility limitations, he has very little available to him to compensate during the swing, leading to more upper body dominated swings (his hip and knee are okay with that) and pulls.

His knee pain makes it difficult to create vertical braking forces on the lead side which would help eliminate the slide and spinning out. His hip mobility limitation also makes it difficult to limit the slide and spinning out without agitating the knee. Last, his missing mobility and motor control in the trail shoulder accentuates his misses and creates a perfect storm for worsening pull hooks.

The plan of care

We had our data and we knew what we needed to work on. Now it was time to organize and prioritize our interventions. We worked over 15 sessions to address the inured meniscus and return to loading through the knee. During this time, we also began addressing baseline and true mobility at the hip and shoulder. Once we began to approach our baseline minimums and could get into deeper knee flexion without pain, we begin putting multiple joints together again to create load throughout the chain. We could then combine this with speed and force development while putting Alex in positions to create rotational and lateral forces that required us to turn and stop in the hip and lead side lower extremity. At this point, he was ready for building up to full swings.

This plan included interventions that worked not only on the knee and hip, but everything from the big toe to the cervical spine was addressed for one reason or another. Without finding and addressing the trail side shoulder external rotation, his swing characteristics that were now leading to more pain and load in the knee would have continued, hindering our progress. That is why it is essential to exam the body entirely and find the common links!

Conclusion

Alex’s case is a clear reminder that pain and performance in golf are rarely isolated to a single structure. What initially appeared to be a straightforward knee issue was, in reality, the result of a broader breakdown in how his body moved, loaded, and created force. His limited lead hip mobility, combined with deficits in shoulder function and lower extremity control, created a chain reaction—one that not only aggravated his meniscus but also reshaped his swing into compensations like sliding, spinning out, and ultimately producing pull hooks.

By addressing the true underlying limitations rather than chasing symptoms, we were able to restore his ability to load and trust his lead side again. As his mobility improved and his body regained the capacity to control force through the ground and pelvis, his swing began to naturally reorganize into a more efficient and repeatable pattern—without forcing technical changes.

The takeaway is simple but powerful: the golf swing is an expression of what the body can physically achieve. When key mobility and stability requirements are missing, the swing will always find a workaround—often at the expense of both performance and long-term joint health. A comprehensive, full-body evaluation is essential not just for resolving pain, but for unlocking better, more sustainable golf.

-Dr. Nick DC, MS, TPI, CSCS

If you would like to learn more about your body, pain, and performance, send Dr. Nick an email at contact@integratedrpc.com or call at (585)478-4379, or schedule a FREE discovery visit at Contact.

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