When Athletes Fail: The Science Behind 'The Yips'

John Watson

Disclosures

February 05, 2019

Charles H. Adler, MD, PhD, a professor of neurology at the Mayo Clinical College of Medicine in Scottsdale, Arizona, has a research focus on neurologic conditions with movement-related symptoms, most predominantly in Parkinson disease. However, for the past two decades, he and his colleagues have conducted several studies[1,2,3,4] shedding light on the sports-related phenomena known colloquially as "the yips," whereby a well-honed action suddenly becomes impossible to perform with the ease it once was. Given how commonly the yips are referenced in sports, it is surprisingly misunderstood. It continues to be used as shorthand for "choking," which places the onus on athletes themselves, who are often called out for failing to succeed in the moments of stress on which sports thrive. Thanks to Dr Adler and other researchers, however, we are beginning to understand that the truth is quite a bit more complicated. Medscape spoke with Dr Adler about the evolving understanding of the yips, determining whether its source is psychological or neurologic, and what it shares with similar conditions in nonathletic fields, from music to surgery.

What Are the Yips?

Medscape: The yips is a term that means different things to different people. What's the best definition?

Adler: In golfers, the yips are an involuntary jerk, twitch, or shake at the time that the athlete is putting or doing other activities, such as chipping or being in full swing. Originally, it was used for putting.

Medscape: Is it a one-time disruption in performance, or does it have to be chronic to earn that term?

Adler: People have used the term for single events, and you can hear them describe it as, "Oh, I think I had a yip." But for most who say that they have or are identified as having the yips, it would be more of a chronic issue than a single, one-time event.

Medscape: The yips is most often associated with golf. Is there something particular to that sport that makes players more vulnerable to it?

Adler: It was first described in golf, and it is well known in golf, but I would say we can't make a comment about how frequently this occurs in other sports or activities. There have been descriptions of this in people who throw darts, and potentially a baseball, but it's not something that has been really looked at in any other sport. Even the amount of data that have been looked at in golfers with the yips is fairly minimal in terms of scientific studies.

Medscape: When did the research community begin to look more closely at the yips, and what was the reason for taking it more seriously than it had been in the past?

Adler: The issue of whether golfers with the yips might have an actual neurologic cause goes back to the 1980s, with a publication suggesting that the yips was a focal dystonia.[5] The topic came up when people started to notice that there were task-specific movement disorders (eg, writer's cramp and musician's cramp), which then got extended to the idea that this could be occurring in athletes as well, specifically in golfers.

Identifying When the Yips Is a Neurologic Condition

Medscape: There's a prevailing idea that the yips is solely a result of external stressors. For example, if you were to take away the pressure to sink a putt, maybe a golfer's yips would disappear along with it. But I understand that's a mistake.

Adler: Correct. It has long been held that this is a psychological disorder, that it's choking. But the issue for me, from a neurologic standpoint, is twofold.

First, in somebody who has a neurologic disorder such as Parkinson disease, tremor, dystonia, and so on -- these all worsen with stress and anxiety, whether it is physical or mental stress.

Second, if you look back at the literature from years ago on other forms of dystonia, such as individuals with torticollis or other dystonic movement disorders, many of them were thought to have a psychological disorder. That's similar to the way we've been approaching golfers with the yips.

Although many may have the yips with a psychologic cause, it's our belief that there's a subgroup of individuals with the yips who actually have a neurologic cause, much like with all these other movement disorders.

Medscape: You recently published a study[4] that laid the groundwork for determining that. Can you describe how you were able to go about doing so?

Adler: One of the biggest problems in the field of movement disorders in general, but specifically with task-specific dystonia, is there's no diagnostic test. Everything is really about looking at the patterns of movement, both at the initial exam and over time.

What we were trying to do in this and other studies was see whether we could find objective measures that suggested that this person had a neurologic, and not psychological, cause of their yips.

We used a number of different measures: Opal sensors attached on the top of the hand and on the forearm, surface electromyography (EMG) pads placed over muscle groups on the forearm, and then the SAM PuttLab, which is a way to measure putter movements. This was the first time we added an actual outcome measure, which was what happens to the putter himself or herself.

We looked at videos of golfers who completed 10 two-handed putts and 10 right-hand-only putts. We separated out all the golfers who complained of having the yips. All of them, when they were examined putting at one point in time, look like they had a yip. Then when we actually put them in the lab and hooked them up to everything, 13 of 27 did not have any evidence of the yips when we reviewed the video of the two-hand putts. Nine of them had evidence of the yips, but it was not the sort of stereotype of looking neurologic. Of 27 golfers in total, five of them yipped more than half of the 10 putts and looked like what one would expect in a very stereotypical neurologic cause.

Medscape: What do you hope to gain from understanding when the yips has a possible neurologic cause?

Adler: The goal would be trying to find treatments. Individuals who have a psychological cause of the yips may well respond to certain types of interventions that relate to training, biofeedback, and so on. However, people who have a neurologic cause may not respond at all to those types of interventions.

By knowing that there's a potential neurologic cause, there may be a medication or treatment that could be afforded those patients that would be completely different than just trying to use interventions related to the psychological aspect.

The bottom line is that I think it's a small subset of people with the yips who have a neurologic cause, and intervention for that small group of individuals may well be different than what you do for somebody who has a psychological cause.

Destigmatizing the Yips, and Understanding Its Consequences

Medscape: Several professional athletes have been thought, accurately or not, to have the yips. The latest high-profile example is the basketball player Markelle Fultz, who was a highly regarded shooter in college but entered the NBA with a mysterious hitch in his shot that he hasn't yet been able to overcome. Cases like this still seem to carry an air of judgment with them, as if somehow the players are just cracking under pressure, almost as if it's a failure of character. How would you like to see people discuss these cases going forward?

Adler: The real issue is that if the yips have a neurologic cause in these players, we need to find a way to identify the cause and then find a way to raise awareness of the fact that this is not psychological in those athletes. Much like with people with writer's cramp and musician's cramp, this needs to be approached in a completely different way than it is currently with a lot of these athletes. That's part of what I'm trying to do in asking whether we can identify objective measures.

And people have asked me whether I can identify this in other sports. The problem is that even identifying it in golfers, who have a very small movement, just putting, has been very difficult. So then being able to extend that type of work into much larger movements would be a potential issue.

But the first step for any neurologist to make a diagnosis of dystonia, or an involuntary movement, is examination, watching the movements to see whether they're stereotypical, whether they fit a pattern.

Medscape: In the grand scheme of things, somebody having a problem with their golf game might seem small, but to the players themselves, I would imagine this causes quite a bit of distress. Are there additional health or psychological ramifications that are associated with the yips?

Adler: Others have tried to look at issues related to depression and anxiety; I have not done that type of work. But I can certainly speak to the fact that it is not a small problem for the individuals who developed the yips, but actually a very large problem.

There are various different levels of golfers who developed the yips. You have the pro golfers whose financial future depends on this, but then you have the recreational golfer whose enjoyment depends on it.

Medscape: If that's your main means of getting exercise, that could be a major issue.

Adler: Exercise, enjoyment, camaraderie, and so on. And that can be for any sport.

Not Just a Problem for Athletes

Medscape: You've noted the overlap with other types of focal dystonia. What are some of the examples of that?

Adler: It's not too dissimilar to professional musicians who develop musician's cramp, which has had marked effect on their careers. The most famous case of this is probably the pianist Leon Fleisher, who became unable to play with one of his hands, which came at an extreme cost to him. There were other musicians, both professional and recreational, for whom musician's cramp has had a significant effect on both their livelihood and enjoyment.

It would be the same for any athlete who wants to perform an activity and now can't do so to the best of the ability they feel they have. It's knocked a lot of people out of golf recreationally.

Medscape: Have you worked with musicians as well? Or has it primarily been with the golf community?

Adler: From a research standpoint, I've only worked with golf. But from a clinical standpoint, I have musicians, I have people who have writer's cramp, teachers and other individuals who lose their jobs because they can't write anymore. So it's all types of focal dystonia.

It's important to put that in perspective. People really get caught up that I'm talking about athletes, and that this is not something that is common. But focal task-specific dystonias are not uncommon.

I think that anything that we learned from the athletes would definitely project to being of interest who individuals with other task-specific dystonias.

Medscape: Given Medscape's readership, I was curious whether there was any evidence of something like the yips occurring in healthcare professionals, perhaps in surgeons performing complex manual procedures.

Adler: Dentists, surgeons, anybody performing fine movements is at risk of developing an involuntary movement disorder, tremor, noncommon movement disorder, as is the general public. If you're an individual who requires their hands for fine motor movements, developing a movement disorder is going to interfere with that.

In those situations, we don't normally call it the yips; we would call it a task-specific dystonia. That's definitely been reported in surgeons, dentists, and in other healthcare professionals, much like writer's cramp.

Medscape: Is there any evidence that the yips would precede a larger neurologic condition?

Adler: For most adults who develop a focal dystonia of the hands, of the neck, of the eyes, it remains focal. There's no evidence for somebody who has a task-specific dystonia going on to develop any other significant health condition that I'm aware of.

Medscape: Last, because you've become well known for this research and are based in Arizona, a state rich in golf courses, I'm assuming you're often asked to weigh in on the best first steps to address the yips. What's your advice?

Adler: For a lot of people dealing with the yips, their first step is to go to golf pros and sport psychologists. But if somebody has a continuous problem with the yips, it's not unreasonable to consider seeing a movement disorder specialist. In the cases of somebody who only has it when putting or doing a specific movement, the examination has to include scrutinizing that movement.

Personally, I have these patients putt in my office and try to determine whether I see any involuntary movement during that activity. Our office is set up so we can use the surface electromyography and monitor movements to look for co-contraction. The wrist flexors and extensors often co-contract at the same time in people with the yips.

But the first step is really to see how prevalent it is, how stereotypical it is, and that would really often require an exam.

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