The Difficulty Abandoning Old Eyes—“Unseeing”

It all comes down to memory. Until you really see the light, you revert back to what your memory dictates.

—Dave McNabb, a wonderful PGA teaching pro, said this while teaching the golf swing.

Even when we must see things differently, we often do not. The following case displays some of the struggles involved in changing beliefs and attitudes.

A CORE MUSCLE INJURY THAT PERPETUATED OLD EYES

When a prominent NFL quarterback suffered a groin injury in 2005, his play suffered, his team staggered in the standings, and the fans grew restless. As time went on, the nature of the damage became public; he had a “sports hernia.” The quarterback didn’t describe his symptoms, other than to say that he hadn’t “reached the point where I can’t go. I don’t see that happening” (Figure 4-1).^1–3

It happened. Later that season, the injury got worse and the quarterback was shelved. He underwent surgery, completed an extensive rehab process, and returned the next season fully recovered. Everything went perfectly—except the diagnosis.

There is no such thing as a sports hernia. Despite repeated use of the term by athletes, coaches, the media that covers them, and even some physicians, “sports hernia” is a deceptive misnomer. There is no herniation that leads to protrusion of abdominal contents. This is not just one problem. There is not just one fix. This is a whole set of muscle injuries that involves the neighboring bones. A better name is “athletic pubalgia,” but that doesn’t sound like something a football player would sustain. And that can actually make some people uncomfortable because of the “pubalgia” part of it. It’s kind of hard to imagine a coach dropping the word “pubalgia” into a discussion of Double-A gap blitzes and play-action passes.

Sports hernia is easy. It seems acceptable.

But it is wrong. The term has led to false assumptions and many off-target surgeries.

Figure 4-1. Star Philadelphia Eagle quarterback Donovan McNabb, known as a mobile, talented passer and runner. Heroically, Donovan played through nearly a whole season with a severe core muscle injury.

The injury suffered by many athletes and nonathletes is, point of fact, a set of injuries. Often, one first tears his/her rectus abdominis, then the psoas, and finally, at the same time, 3 adductor muscles on each side of the body. The name we want you to use today is core muscle injury. We are talking about the core—the lower back, hip joint, and skeletal muscle of the pelvis. Fortunately, he had no hip or back involvement. The core muscles get injured in sports and other activities, alone or in combination with the hip and back. These are core injuries and core muscle injuries. This quarterback’s case opened many eyes with respect to the existence of these injuries.

The publicity generated also set us way back in terms of understanding these injuries. All of a sudden, the whole world “understood” these injuries were all “hernias.”

This case, and Figure 4-2, illustrates the problem with old eyes looking at this quarterback’s problem. His injury, in fact, was complex and required a sophisticated repair. Nevertheless, the publicity generated by his injury reinvigorated more and more surgeons to use their old eyes and treat these injuries, again, like hernias. As Proust warned, they sought the “same ol’” horizons (Figure 4-3). Inappropriate hernia repairs for these complex musculoskeletal injuries increased 10-fold.

Figure 4-2. A severe core muscle “harness” injury. (A) Sketch of a severe core muscle injury in a bull rider on the operating room table with the area of incision. The parallelogram represents the frame of the intraoperative photo and the contained ellipse the skin edges in that photo. (B) Intraoperative photograph of the injury. (1) The retracted, avulsed rectus abdominis stump is above the left retractor and not shown. (2) The right forceps holds a stump of adductor. (3) The left forceps points to a subtotal avulsion of the pectineus muscle. (4) A hollowed-out right pubic body glistens behind the right forceps.

Figure 4-3. In medicine, old eyes often get obscured by our own instruments. Physicians will see the humor in this picture. A physician is looking through a device meant for reflecting light and not a telescope. The reflector should be on top of his head and not obstructing his vision.

The quarterback’s injury highlighted the realization that we were not effectively conveying our findings from the Eureka moment. By 2005, we had repaired thousands of such core muscle injuries. Yet, most of medicine, and certainly the public, still knew nothing about these injuries. Obviously, despite all our presentations, the knowledge had not disseminated well. It was frustrating (Figure 4-4).

Figure 4-4. In 2005, the old concept of “sports hernia” still festered. The aforementioned quarterback’s injury disseminated incorrect notions and treatments of core injuries (A and B).

The doc in Figure 4-3 represents the same ol’ docs we encountered in previous chapters, the ones with “old eyes,” the eyes we had to make “unsee” what they were seeing. For years, people presumed occult hernias were the heart of the problem. And most nonsurgical health care professionals just took it for granted that hernias were the problem. Figure 4-5 shows an ultrasound that greatly aggravated the problem further.

For years, it has been known that ultrasonography can make things look like hernias by a combination of varying the locations of the probe and different types of straining. True hernias may, in fact, look like this on ultrasonography, but one can produce these findings in people who do not have any semblance of a hernia.

The unseeing problem here is sort of like the concept of group-think that led to the space shuttle Challenger disaster.⁴ In that disaster, you will remember, sets of real data escalated a mistaken belief, held by multiple experts who all worked together. The final analysis was wrong, and the space shuttle crashed. In this case, a general surgeon predisposed to thinking that pelvic pains in athletes is all due to occult hernias listens to a radiologist who calls an occult hernia on an imaging study. What happened next? Of course, the surgeon, inclined to do a hernia repair, believes the ultrasound report and puts his/her instruments to work. “Another successful repair!” might be stated when the surgeon sees the patient 2 weeks after the surgery. But for how long is the patient followed? How well does the patient really do?

Unfortunately, copious medical literature does exist that supports such diagnostic and surgical approaches. As poorly as the articles may be written, they cannot be “unwritten.” The problem is a big one. It gets back to the discussion of Aristotle and Hume, etc, and the big flaw in empirical medicine (ie, “knowing” things with more certainty than our senses are telling us).

With respect to the core, physicians need to see more clearly what is really happening.

Figure 4-5. Ultrasounds exacerbate the deception of old eyes. This set of images shows how an ultrasonographer can generate what looks like an inguinal hernia during abdominal straining. The arrows point to supposed alterations in the musculature. Such alterations are normally seen with Valsalva maneuvers. The bottom line is that this sort of image can be produced in just about any person undergoing this dynamic examination.

Let’s next address the state-of-the-art as it looks in the present literature. You will “see” that most authors still have not acquired new eyes.

WHAT HAS THE LITERATURE BEEN CALLING THESE PROBLEMS?

A year ago, I was asked by an orthopedic journal to do a review of current literature on “athletic pubalgia.”5 Even for me, having devoted 30 professional years to this topic, it was tough to even write an opening sentence for the requested literature review. “Thorny” may be a better adjective, because a quick read through the various literatures exposed so many different, often intensely competitive, biases and interests. So, any critique was likely to provoke massive grousing. My 2 goals for the review swiftly became: (1) to build some common ground, and (2) if that were not possible, to, at the very least, keep the moaning of therapists locked into old eyes at lower decibels.

Understand that the literature on this overall subject has been a mess. So, 3 colleagues and I asked 2 simple questions. The first was: What literature exactly should we review? The term athletic pubalgia came from a 1989 paper we presented at the 15th annual meeting of the American Orthopedic Sports Medicine Society.⁶ There, we had proposed the term as an alternative to sports hernia because it accurately depicted, in a general way, the anatomic location of a set of pains so potentially disabling for athletes. At the time, we also knew that general surgeons would flunk their American Board of Surgery oral boards if they mentioned that other term. That latter fact emphasizes that no one in 1989 understood this pain. At that 1989 presentation, we believed athletic pubalgia potentially involved a lot of different muscles and bones intimate with some pretty important organ systems.

Keep in mind that at the time of writing this review in 2014, there were countless quasi-scientific articles on this subject. They appeared in all kinds of journals, dealing with all aspects of physical therapy, fitness health, and medicine. Some of the better articles, which we could not ignore, happened to be in popular periodicals targeting the general public. Therefore, for the purposes of this review, we chose to review only the English-written literature over the past 2 to 3 years, but not to totally ignore selected articles before that. We began with Google and PubMed web searches.

The second question we asked for this review was: What do authors call these injuries today? We simply tallied the first 100 seemingly appropriate articles, using 5 rules:

We searched only the time interval 2012 through 2014. Articles from other years, of course, did pop up.
We did not search with terms that would obviously bias the results (eg, sports hernia, athletic pubalgia).
We did not read articles with titles about noninjury problems (eg, inguinal hernia or gynecologic pain), unless the title suggested they might discuss injuries.
We excluded generally descriptive terms (eg, pelvic pain in athletes).
We lumped together similar terminologies (eg, sports hernia and sportsman’s hernia). Tables 4-1 and 4-2 show the results.

TABLE 4-1 TOP FIVE TERMS FROM GOOGLE
1. Sports hernia	63%
2. Athletic pubalgia	12%
3. Core muscle injury	8%
4. Gilmore’s groin	6%
5. Hockey groin	3%

TABLE 4-2 TOP FIVE TERMS FROM PUBMED
1. Sports hernia	41%
2. Sportsman’s groin	24%
3. Athletic pubalgia	18%
4. Core injury	2%
5. Adductor injury	2%

Interestingly, the Top 5 from PubMed and Google were not much different. One might have expected more anatomic precision in the PubMed articles, but that did not happen. The most striking difference between PubMed and Google was the use of quotation marks around the term sports hernia. That occurred in more than 70% of the PubMed articles and just 13% of the Google article titles. From the latter observation, we surmised 2 points: (1) the authors of the articles from PubMed were indeed thinking more scientifically (ie, trying to be more accurate), and (2) the authors may have believed these injuries were not hernias.

The bottom line from this recent literature review was that people clearly no longer trusted their previous eyesight; they knew multiple injuries were operative. Plus, they knew these were not hernias. Yet they saw no consistent concept emerging. Therefore, people still labeled all these things sports hernias or pseudonyms reflecting the pathology as some kind of “inguinal disruption.” Most therapists were continuing to treat all these problems by their own “trusted” methods, usually one fix for all the pathologies encountered. The “fix” always represented their training. That line of thinking also reflects the aforementioned inherent flaw of empirical medicine—“knowing” things with more certainty than what our senses are telling us (see the last section).

What the heck? Consider the frustration.

THE DIFFICULTIES

So, the literature still, mostly, reflects an impasse in understanding these injuries.

The previous chapter describes the importance of an impasse to the actuality of an aha! moment, but does not describe why a simple understandable solution to that impasse may not be immediately accepted. Logic would say that scientists would believe it. After all, this is not Christopher Columbus saying the Earth is not flat.

Perhaps we are more like Copernicus, with his De revolutionibus orbium coelestium, when he said the sun and not the Earth is the center of the universe. Sixteenth century religious leaders led a tempestuous charge against Copernicus, who “fortunately” died before the scorn reached full throttle.

Okay, it is not the same. This is not a religious thing. Or is it? We are saying the pubic bone is the center of the body’s universe. Everybody already knows that, don’t they? Maybe…but certainly not in a functional anatomic sense!

We do see reasons for the lack of acceptance of this “Copernican” understanding. The primary reason may be that this book hasn’t been published yet. But we have written a great deal in peer-reviewed journals. Likely, the writings have gotten lost within the very confusing literature outlined previously.

We believe the primary reason for the lack of understanding of this concept is the “things you cannot unsee” theory about how the brain works.7 The second reason people may choose not to accept the concept is because it conflicts with their presumptions, and sometimes their training and well-being, similar to the weakness we discussed of empiricism (Figure 4-6).