JASON HARTMAN, DO
PHILIP J. KOEHLER III, DO, MS
VERONICA WILLIAMS, DO, ILLUSTRATOR
Editor’s Note: My osteopathic colleague Jason Hartman pens his perspective on the core. It is very different from mine. Yet, Jason’s profound understanding of the anatomy and integrative approach encompasses what the core is all about. Jason is transforming me into a believer. Jason invited one of his gifted students, Philip, to join in the writing of this chapter. Another of Jason’s talented students, Veronica Williams, illustrates this chapter.
It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
—Sir William Osler, considered the ultimate diagnostic physician ever.
This whole chapter constitutes a plea for all health professionals who participate in the care of athletes, and everyone else who desires to stay fit, to think out of the box and in terms of manipulative therapy. Manipulative medicine is where it is at. (See Figure 37-1.)
Osteopathic manipulative medicine sanctions more than 30 categories of manual manipulation that incorporates thousands of distinct techniques. Osteopathic physicians commonly employ just 4 broad categories of techniques: soft tissue, high-velocity-low-amplitude (HVLA), myofascial release, and counterstrain1 (Figure 37-2). A recent meta-analysis and systematic review revealed that manual modalities and multimodal treatments shorten the return to play time for many high-level athletes with core injuries.2,3 Ask yourselves the following question: If this is true for athletes, why should manipulative therapy not work for all of us?
A STRAIGHTFORWARD SENTINEL CASE
Mary, a 60-year-old athletic female with osteoarthritis of the left hip, gets referred to my office for manipulative therapy after many years of left-sided pubic area pain that had taken her away from recreational running and most other physical activities that she enjoyed. After initial assessment, I sent her for rectus abdominis core muscle repair. Thereafter, she faithfully employed manipulative therapy, and she has done extremely well for the past number of years.
For a long time before Mary came to us, her caring physicians identified her as another aging patient experiencing a “typical” progression of hip arthritis. Mary was being viewed through the old lens of structural reductionism. That was unfortunate. We had to ask the question: “What if her new physicians had seen her 20 years earlier? Would that have altered her outcome?”
We were the ones who asked the question. Of course, the answer is yes.
Reductionism is the philosophy that molecules constitute all systems, and the interactions of molecules establish all hierarchies of chemical, biological, and physical properties. The earliest reductionist was Thales (born circa 636 BC in Asia Minor), who hypothesized that the fundamental substance of the universe was water; water composed all things. Descartes, the mapper, became the most famous promoter of this philosophy.4
We propose the term structural reductionism as a narrow condensation of reductionism to just the musculoskeletal system. Basically, this philosophy means restoration of the proper structure to the body restores function. Traditional medicine abides by this approach, but in an even narrower way. Their approach assumes a paradox that different structures within the musculoskeletal system can function independently from each other; yet, if you fix just one thing, you can fix it all.
In short, traditional medicine goes by the philosophy that pathophysiology can be reduced to a simple defect in a muscle, ligament, bone, or other relevant structure and does not have to take into account the complexity and interdependency of the whole organization (ie, the overall form and function). Of course, we are exaggerating somewhat its philosophy. Hopefully you get the point.
Osteopathy breaks this mold. It looks at the body as totally connected components. In this chapter, we want you to become Descartes. View the universe as water. That way, you will broaden your scope and see how to manage the entire body.
Structural reductionism occurs at all levels of health care. Health care professionals at the front line of musculoskeletal complaints—massage therapists, athletic trainers, physiotherapist, and physicians, to name a few—usually perceive pain through the lens of structural reductionism. The result is that they will achieve success in a certain percentage of patients, but will not in others because they cannot access the full spectrum of problems.
PUBIC PAIN—THE WAY IT WAS
Just like in our sentinel case, the physical exam is the only place “it” is at. The site of pain determines most everything. The diagnosis is a rectus abdominis issue. Treatment begins with rest, ice, nonsteroidal anti-inflammatory drugs, and then corticosteroid injections; when that ceases to work, surgery comes to the rescue. This is diagnosis and treatment by mode of structural reductionism. Six months later, adductor pain begins, and then anterior thigh pain. Then other things happen.
CORE PAIN—THE WAY IT SHOULD BE
Manual therapies help us understand the body from a wider perspective. The roots of manual therapies involve “holism,” effectively the opposite of reductionism. Holism traces back to Aristotle: “The whole is more than the sum of its parts.”5 Likewise, each medical disorder is more than the sum of enzymatic or cellular dysfunctions.6
We are applying Aristotle to the musculoskeletal system. Think of the musculoskeletal system as complex yet interdependent anatomy.
This system functions as a whole and has units beyond regular Newtonian dynamics. The functional units—call them biokinetic chains—influence each other. When one chain falters, the entire system falters. One simple dysfunction affects posture, gait, movement, and the homeostasis of the entire musculoskeletal system. We need everybody to believe it is naive to think that dysfunction can be solved only by the simple reapproximation of a defective attachment. Human movement and posture are determined by complex interactions between bones, joints, muscles, ligaments, nerves, blood vessels, lymphatics, and hollow and solid viscera.
Let’s turn back to Mary. In other hands, Mary might have been treated in a more “holistic” manner. From the initial assessment, she would have undergone analyses of movement, gait, and posture. She would have been observed to have a functionally short left leg, pelvic torsion, and an internally rotated hip. She would have undergone complete evaluation of the hip, and that would have revealed laxity of her hip capsule. Mary also would have multiple myofascial trigger points (MTrPs) involving her hip flexors and adductors. She also would exhibit extensive functional weakness of her glutes, which would have contributed to her generally weak core.
Various conceptual frameworks have been applied to explain what manipulative therapies address. Among these is osteopathy. We shall also discuss other therapies, to some extent, in this chapter.
The key to being a great goalkeeper lies in the strength of the core.
—Gordon Banks, the best soccer goalkeeper of all time, and not just because he said this.
Osteopathic philosophy emphasizes looking at patients in the entire context of their lives, and not just their chief complaints. When we talk to and examine a patient, we keep 4 doctrines in mind:
- The person is a unit, all organ systems connect.
- The body self-regulates, self-maintains, and self-heals.
- Structure and function interrelate complementarily.
- Rational treatment comes from understanding the above 3 doctrines.
Patients with pelvic pain often have a myriad of somatic and visceral complaints. For example, patients with interstitial cystitis see 5 to 7 physicians before the diagnosis is made. Like patients with Crohn’s disease or angina, they have multiple co-morbidities. They are 2 to 3 times more likely to suffer from low back pain or tension headaches, and 10 to 20 times more likely to have fibromyalgia or vulvodynia.7
There is no doubt that these patients have neurologically mediated reflexes that go in 2 directions, from the organs to the musculoskeleton (viscerosomatic) and vice versa (somatovisceral). The reflexes lead to a heightened neurologic state and easy excitability of both the central and autonomic nervous systems, so much so that it becomes impossible to distinguish between the chicken and the egg. Successful treatment of the patient has to break that vicious cycle. It must somehow shrink the ease with which the central and autonomic nervous systems bolt into the picture. Success requires multidisciplinary approaches targeted at both somatic and visceral pathologies. (See Figures 37-3 and 37-4.)
We must ask about the problem’s chronicity, exacerbating and alleviating factors, previous medical or manual treatments, lifestyle, and psychosocial and other factors that might help design optimal ergonomics (eg, typical day at work, leisure, and exercise). We must do a complete review of systems and complete sexual and surgical histories. All organ systems and past treatments apply. This knowledge base helps design optimal manual therapies.
The Structural Exam
The purpose here is to identify physical problems (ie, somatic dysfunction). Somatic dysfunction, in essence, indicates the need for osteopathic manipulative therapy. The diagnosis of somatic dysfunction requires at least 1 of 4 criteria: tenderness, tissue texture change, restricted range of motion, and asymmetry. There are 3 parts to the structural examination: observation, palpation, and functional assessment.
Observation begins when the patient walks into the office and continues throughout the visit. Look for motion abnormalities of the pelvis or postural or functional compensations that might be secondary to pain or structural discrepancies. Spot antalgic gaits, asymmetries of normal anatomic landmarks, and posture and possible pelvic tilt imbalances. Here is when we might pick up upper/lower cross syndrome, iliopsoas syndrome, short-leg syndrome, an anteriorly rotated pelvis as a result of hip flexor and erector spinae hypertonicity,8 or a posteriorly rotated pelvis due to hamstring hypertonicity.9
Palpation begins with a static exam. Palpation might find acute or chronic changes of hypersympathetic tone with chronic texture changes. The tissue may feel cool, while looking pale and mottled, or boggy with a fibrotic ropy muscular texture.
We might start with the pubic bodies and/or rami and look for tenderness, then the various muscles, ASIS, PSIS, and back. We check for alignment. For example, we may palpate a posteriorly rotated innominate bone on the left, and confirm this with a cephalad left medial malleolus. Then we know we are working with a short leg on the left. From the static palpation exam, patterns arise, from acute or chronic trauma, poorly healed injury, or various postural forces. The more chronic the patterns, the more compensatory layers appear.
We examine all the core muscle groups detailed in Section One of this book. We identify “trigger points,” areas when touched or otherwise stimulated set off cascades of pain. Trigger points travel along predictable “Travellian” lines or with spasmodic or chronically contracted muscle. Leg shortening signals the possibility of an ongoing protective mechanism and atrophy resulting from fatigue and weakness.
Next, we examine the ligaments of the core (eg, inguinal, pubocapsular, sacrotuberous, sacroiliac, iliolumbar). Pelvic or hip instability may manifest itself along ligaments. We look for the same patterns of tenderness and texture. Instability often creates alterations in the location of trigger points. That, by itself, can be a clue. For example, hip instability often manifests at the pubic symphysis or one of the bodies, owing to massive compensatory shifts.
The final level of static palpation is the fascia and other connective tissue. The book Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists by Thomas Myers10 dedicates itself to understanding the continuity of connective tissue throughout the musculoskeletal system. An important fascial level is the obturator internus fascia, which becomes continuous with the adductor fascia. Fascial lines connect the adductors to the contralateral rectus abdominis on top of the pubic plate and contribute to the physical therapy concept of slings. Manual techniques sometimes aim to normalize the forces across those planes and balance core. A small fascial disruption may disrupt a delicate balance and create major dysfunction. Resultant alterations in posture and movement create an instability and susceptibility to injury.
Functional assessment becomes the primary assessment tool after completion of the history and the first 2 parts of the structural exam. At Vincera, we developed resistance tests for each of the core muscles attaching to or crossing the pubic symphysis or joint (Figure 37-5). Interpretation of each test involves 3 considerations:
- Does the test cause pain?
- Does the resultant pain correlate to the muscle being tested?
- Does the resultant pain recreate the pain causing the athlete’s disability?
For the hip, functional assessment means primarily range of motion without interference from contracting muscles. These include the standard flexion-abduction-external rotation (FABER) and flexion-adduction-internal rotation (FADIR) tests, plus other rotational or hyperflexion/hyperextension tests aimed to isolate anterior, posterior, or lateral impingements or other pathology. Nearby tenderness sometimes helps solidify diagnoses, but pain may also come from more remote inflammation and cause confusion.
- FABER/Patrick’s test
- Thigh thrust/femoral shear test
- ASIS distraction/compression (supine)
- Sacral compression (lateral recumbent)
- Standing and seated flexion tests