Optimizing and Fixing the Core Muscles

optimizing and fixing the core muscles

I was a great athlete until I was 7. Then I took time off. Now I can beat most of my friends in tennis because they have artificial hips and knees.

—David Rubenstein, Co-Founder and CEO of The Carlyle Group.

LIFE IS A CONTINUOUS PROCESS

David Rubenstein’s quote says it all. Life subjects the body to all kinds of stresses that may not be good for us. Sports or other strenuous activity exposes muscles and joints to continuous microtrauma. Unequivocally, wear and tear eventually gets us. We call low-grade deterioration degeneration or, more euphemistically, interstitial tearing, and the more serious harm injury. Injury is inevitable when we perform the same activity repeatedly or hard enough. Athletes routinely experience the paradox of preparing themselves for short-term gain vs sacrificing their bodies in the long term. Simply said, fitness ultimately leads to injury.

Not only does staying in great shape stress our bones and soft tissues, it challenges our heart, brain, and longevity.1–3 Is exercise good or bad for us? Believe it or not, the subject is controversial. Cardiologists and fitness specialists have argued about this for years,^4–7 the risk of sudden death, etc. The recent pandemonium about concussions represents the controversy’s latest chapter.

As you read on, keep in mind that the editors of this book are biased. We subscribe to the point of view that staying in shape is good, that life creates a wear and tear called the aging process. We, as therapists, truly believe we can affect this aging process. No matter how good we may be at minimizing age effects on muscles, bones, and joints, we must recognize that our opinions represent a bias. We could be wrong—staying in shape may really be bad for us. Some really smart people believe that staying in great shape is not a good thing.⁸

TWO IMPORTANT QUESTIONS

This chapter addresses how to answer 2 questions (Table 21-1):

How good a shape do we need or want to be in?
When we truly do injure something…when, why, and how should we fix it?

With regard to Question 1, you should know by now that the core is the “engine room” for getting into shape. Most of this chapter focuses on answers to Question 1.

Before getting too far into the first question, let’s concentrate for a moment on Question 2. One must consider certain practicalities with regard to Question 2. Consider the practicality that if you ask almost any physical trainer if he/she knows much about the core, virtually all of them will tell you yes. They will go on and tell you they are experts. Realize that, in fact, only a few of them really are. The same thing is true in spades about surgical treatment of the core. For example, more and more hip arthroscopists are being trained. Yet, almost everyone in the field will say that the more experienced you are, the better are your results. Plus, only a few surgeons yet understand the principles of core muscle surgery, and truly know how to fix those injuries.

TABLE 21-1

THE TWO BASIC QUESTIONS—REPHRASED

What do we mean by “good shape”?
When, why, and how should we fix an injury?

That is because there is no formal recognition of this new field, which we call the core, in medicine. Most physicians don’t understand it. The functional anatomy is not taught in medical schools. None of the core muscle anatomy, pathophysiology, or procedures has been incorporated into medical schools or residency training programs. And many insurance companies refuse to pay for the surgery. Instead, the executives label any such surgery as “experimental.”⁹ Therefore, surgeons who dabble in this region of the body list the procedures under existing codes (eg, hernia repair, tendon division). The code “hernia repair,” in fact, oftentimes represents the procedure that the surgeon is doing. The problem is that the diagnosis and treatment is wrong. But with that false mindset, the surgeon will say, “Why not code the procedure this way?”

In turn, the billing/insurance problem perpetuates that old mindset and ancient eyes. Because many of the procedures are unsuccessful, those results add fuel to the insurance companies calling the procedures experimental. Consequently, the inaccurate coding and terminology perpetuate the term “sports hernia.” All this cultivates the insurance companies’ argument against new procedures. Because they see many of the failures, their arguments become stronger and have more ammunition for a demand for a randomized prospective study, which they know will never be accomplished. How do you ask a star athlete with a muscular avulsion to subject him-/herself to a 50/50 chance of not getting the surgery?

The result is a vicious cycle, a Catch-22 so to speak. If you call a new procedure by an appropriate name, you just don’t get reimbursement. The consequence of all the above factors is that surgeons, for the most part, become more likely not to do the right procedures. Much of the surgery presently going on is predictably unsuccessful. The answers to Question 2—when, why, and how to fix the injuries—presently depend on how aggressive or knowledgeable the patients or caretakers are with respect to seeking out optimal treatment. (See Figure 21-1).

This chapter brings together the principal factors that should enter decision processes for the above 2 questions. It provides guidelines for how to answer the questions. It does not provide the actual answers. Chapter 30 gets into more specifics about how to fix things, but still offers only guidelines. The present chapter is short and sweet. Therefore, please allow the main themes to marinate in our brains, so that they infuse smoothly into our psyches. Like other walks of life, the questions “when” and “why” eclipse the queries “how” and “what.” The rest of this chapter focuses on the answer to Question 1.

If it ain’t broke, don’t fix it.

—This expression is commonly attributed to T. Bert Lance, Office of the Management of the Budget Director in the 1977 Jimmy Carter administration. In fact, this is an old Southern proverb. My grandfather, a carpenter from South Carolina, delivered this exact same advice to me way back in the 1950s.

WHAT DO WE MEAN BY “GOOD SHAPE”?

The above proverb sounds like medical school’s cardinal principle: Primum non nocere—first, do no harm. This principle brings up another apparent paradox. If getting someone into the best shape means having to cause deterioration in his/her joints and muscles, doesn’t that go against medicine’s cardinal principle?

Well, get over it. We must get over that paradox. We have already admitted bias. We believe staying in shape is good for us. Let’s modify our goals and ask: How good a shape should we get people into? Plus, let’s ask a corollary to that question: How do we best prevent injury or disability in the short or the long run?

Figure 21-1. Surgical repair of a severe core muscular injury.

Getting into shape is sort of like drinking wine. They say drinking a glass of wine a day is good for you and some studies say drinking 2 glasses a day is even better. When does that stop? How many glasses does it take to cause harm? What’s the right number of glasses?

—Paul Tiffany, Berkeley and Wharton business strategy professor, made similar declarations about loans, credit ratings, and how much money a business should optimally borrow.

Therefore, we shall define the term fixing in this chapter to mean “optimizing the body for desired performance.” This definition may apply to either the short term or the long term, or both short and long terms.

Think in terms of 3 categories of clients/patients/athletes (Table 21-2):

Those seeking to be in the best shape for short-term performance almost no matter what (eg, preparing for the NFL Combine or the upcoming season, making a team) to “feeling good” or to “look more attractive”
Those genuinely looking to get into or “back into” shape for far-reaching health purposes
Those with mixed motivations (eg, some veteran athletes, patients with lawsuits, and, in some cases, worker’s compensation claims)

Of course, we all run across various blends of the above categories. Basically, we treat the 3 categories differently. For the first, it is all about various professional, personal, or social contracts. Short-term performance goals dwarf long-term injury concerns.

One needs to keep in mind, nonetheless, that the patient/client in this first category has only chosen the moment and, for the most part, ignores the long-term consequences. Hence, in this first category, it is imperative that the therapist achieve complete trust. The trust comes from an unwritten conspiratorial pact that the therapist will bring the athlete right to the edge of the cliff but won’t let him/her go over it. The other 2 categories do not mandate the same degree of collusion.

TABLE 21-2

THREE CATEGORIES OF CLIENTS

Short-term purpose
Health purpose
Mixed purpose

The second category characterizes for most of us what should be the right balance of short-term success and body preservation. The creepy third category heralds all sorts of murky interactions that shall most likely lead to many frustrations related to conflicting agendas.

Provided the therapist has the right skill sets, it should be relatively easy for therapists to deal with people in any of the 3 above relatively uninjured categories. They all just want to get into optimal physical shape. As mentioned, optimal shape means different things depending on the motives. For the most part, the transactions involve just 2 parties, the patient/client and the therapist. Of course, one may argue the latter point with respect to the creepy third category. Nevertheless, therapy programs all come down to identifying and uniting goals.

Whatever the case, in all 3 categories, therapists must be extremely careful. We see many core muscle injuries that result from therapists being too aggressive with both the ultimately in-shape bodies as well as the ridiculously out-of-shape bodies. We also see frustrations and dissatisfaction related to therapists not being nearly aggressive enough.

The “perfect-storm for core injury” comes when a previously in-shape athlete gets out of shape over several years while beginning a family or working hard at his/her regular job, and then becomes determined to pursue, purely on his/her own, an aggressive P90X-type workout program. Talk to the receptionists at the Vincera Institute. They will tell you how common this perfect storm scenario is. Based on their initial phone conversations with new patients, they will tell you that this perfect-storm scenario is really common. Likewise, it is so easy for us as therapists to get caught in the same “enthusiasm trap” and work out these individuals way too aggressively. It is so tempting to do so. They are so highly motivated and enthusiastic. We therapists just have to be careful.

Let’s now go to the more complicated Question 2.

FIXING ACTUAL INJURIES

If it is broke, fix it. When, why, how?

Let’s get into how to go about answering the 3 parts to the question, assuming an unambiguous diagnosis of a specific core muscle injury has already been made. First, let’s itemize possible variables that might be important for the decision-making, then list general guidelines, and, finally, provide a few real case examples. Understand that we are talking about either athletes or everyday people like us.

Decision-Making Factors

Begin by thinking comprehensively about all possible variables that might be important for management decisions. Think about 5 categories of variables:

The injury itself
The patient
Other people involved
The goals
The environment

Don’t worry, you will soon understand what we are talking about.

The injury must have many characteristics. Here are some of the questions that have to be asked. What specific muscle or muscles are involved? Is there a primary injury and one or more compensatory injuries? What part(s) of the muscle is (are) injured and how severe is the injury? Is it a central or a more peripheral injury? Does it involve harness or power muscles? What about the hip, is it involved? What about other new or pre-existent injuries? Is this an acute or chronic injury or a combination of the two?

The patient never quite fits into a precise, preordained category. The variables are numerous. There are the standard patient demographics, such as age, gender/sex, location, insurance status, etc. What is the general physical condition? Is this an athlete? How good an athlete? Is the injury important in terms of functioning in one’s job or everyday life? What sport or sports does he/she play or participate in? Are we talking about a professional or top amateur? Is this a recreational athlete? How important is that sport or are sports in general to the person? How important is staying in shape in general to that person? I bet you can think of many other questions that could be asked.

Others involved can mean many people (eg, for professional or top amateur athletes) or no other people (eg, for the pure recreational athlete). In the latter case, management decisions become more purely a matter of what the patient wants. Think about the number of folks who might be involved with a top athlete: the team’s management—general manager, head coach, other coaches, athletic trainers and physical therapists, the athlete’s personal therapists, the agent, family, entourage, and even sometimes the public, the list goes on… All might become part of the decision-making tangle.

The goals of each of the various parties may be drastically different from the others. The team may be in a playoff race and management wants the player back at all costs, the agent may not want the player to return because it is near the end of the season and the agent sees the downsides of not playing well and no upsides of playing well. It may be the contract year, in which case the motivations of the various parties usually differ drastically. A spouse may want the veteran athlete to quit. The player may already be thinking retirement. Numerous scenarios arise.

Finally, let’s discuss the environment. This is a miscellaneous category that captures all the other factors that may contribute, such as when did the injury occur (eg, during or after the season)? Did the athlete play with injury all year? Does he/she want it fixed so that it doesn’t bother him/her during the next season? Or, consider the scenario: there is one remaining NFL playoff-determining game, it is the player’s contract year, and the player knows he won’t play well in below-zero weather.

Or consider the “university” situation. What do the financial decision-makers at a given university understand about the nature of these injuries? Will the university require the player to have a “hernia repair” at its own local hospital where they have a good financial deal? Many kinds of scenarios come into play; thus, we have this miscellaneous category of decision-making variables.

Fifteen Guidelines

These 15 are listed purely as general principles to shape thinking with respect to decision-making and not as absolutes. This is a selected list (Figure 21-2). Numerous exceptions exist for each of the “guidelines.”