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the eureka moment for the core

A COMMON SCENARIO

You are lying on your couch on Sunday afternoon, watching a pro football game on TV (Figure 3-1). And someone gets injured. Consider what you know about sports injuries.

The announcer says—and you agree—that a player hurt his knee. Immediately, you start going through the possibilities. You feel confident in your knee diagnoses. Keep in mind that you are an avid football fan and not a doctor or trainer or anything else connected with health care. Whether or not you are managing an important fantasy football team, you feel pretty confident in your knowledge base. You think about the specific diagnoses and degrees of severity. It could be just a little muscle strain or bruise, and he will be back playing after just a few plays. It could be “cartilage.” If so, he could possibly return, but more likely he will require quick arthroscopic surgery and be back in a few weeks. A collateral ligament is a possibility. That is worse and would take maybe 6 weeks. Hopefully, it is not the dreaded anterior cruciate tear. Then he’s cooked for the season, maybe longer.

A Eureka, or “aha!”, moment, refers to a common human experience of suddenly understanding a previously incomprehensible concept.1 It is named after a myth involving the ancient Greek scholar Archimedes, who realized, while sitting in a public bath, how to measure the volume of an irregular object. At that moment of realization, he leaped out of the bath and ran home naked, yelling, “Eureka!,” which means “I found it.” Most people who saw him running probably didn’t yell “Eureka!” They probably said, “Put some clothes on.” As the story goes, Archimedes had been asked by a king to determine whether a crown was pure gold or a cheaper imitation laced with silver. While climbing into the bath, he noticed that his body displaced water as he sank into it, and that the volume of water on the floor probably equaled the volume of his body immersed in the water. Since gold weighed more than silver, a crown laced with silver would be bulkier in volume than a pure gold crown if the 2 crowns weighed the same. He would tell the king in the morning! The story is probably fabricated, since the weights of crowns were never measured. But that doesn’t matter. One thing for sure, Archimedes was not thinking about his core. His capable core must have facilitated his getting in and out of the bath tub effortlessly, and then his running down the street after the epiphany (Figure 3-2).

Injuries to the core have always been abundant. All of us probably remember teammates, friends, or family who could not perform well because of the pain “down there.” I remember my mom never being able to help to load our station wagon when we packed for vacations because of some kind of a mysterious pelvic pain. Inevitably, our loading experiences would turn into fiascos reminiscent of the Chevy Chase movie Vacation (Figure 3-3).

When I was a soccer goalie at Harvard, I befriended a highly recruited football player, Richie Szaro (Figure 3-4), who had been brought to the school with big expectations. But he developed a nagging injury in his groin that prohibited him from playing his position as running back. Even though Richie was in obvious pain, the coaches and The Harvard Crimson considered him something of a malingerer. Broken bones kept players off the field. So did torn ligaments. But a pulled groin? Suck it up!

I know now that this player was not faking. At the time, I knew he did not have the usual muscle strain, which, by itself, can be debilitating. Now, in retrospect, he most likely sustained a core harness muscle injury that could have been fixed, had this happened today, with surgery. Of course, that perspective comes from now and not back then. The bottom line then was that Richie had something bad. He was not faking. All his locker room mates knew that.

The old, hard-line, dictator coach of the 1960s and 1970s embodies the state of our knowledge about groin injuries until recently. Anyone who complained of them was just not tough enough. Most of us have probably had coaches like this. They weren’t typically thoughtful. They did not wonder what bothered the player, show empathy, and then seek an answer. Most coaches back then were pretty powerful and just not like that (Figure 3-5).

In fairness to those coaches, the fact was that most doctors in that era had no clue about this set of injuries. The pelvis remained a mysterious, forbidden area, and without a dependable fix for the injuries, there was really no purpose for a coach to think differently. Coaches strove for team wins, and players with unfixable, disabling injuries contributed nothing to that.

Even back then, people talked about “sports hernias.” Since the physicians didn’t have an idea what was happening to these athletes, it made sense that the term stuck, at that time. Beginning in the late 1970s, the term received a bad name in the medical community. The outcomes from hernia repair in athletes and others with inguinal pain were so predictably bad that it became verboten for general surgeons to perform repairs in the absence of demonstrable hernia.^2–5 Surgeons who had finished their training would flunk their oral examinations if they mentioned the term.

EXHAUSTING MEDICAL KNOWLEDGE BASES

The athlete with debilitating core pain would painstakingly go through multiple medical hoops. The rigors of medical and surgical training turn doctors’ eyes into powerful microscopes that look for diagnoses that they know. We as medical doctors see things clearly through the lenses with which we are supplied. By its nature, training limits our supply of lenses. When people had groin pain while doing activities, they would go to multiple different specialists (Figure 3-6).

Then, the pelvis remained a mysterious anatomical region, and it remains that way for the most part. The private nature of the pelvis has something to do with this, but the main reason is that each of us (eg, physician, surgeon, physical therapist, athletic trainer) is biased by our own specific training. It is difficult to see beyond that. As mentioned, the urologist sees the pelvis as the ureters, bladder, testicles, etc. The general and colorectal surgeons think of this region as where the colon and rectum reside, as well as some protrusions called hernias. Gynecologists see what they see. You get the idea. Specialists, as the term implies, naturally hone in on what they concentrate. Orthopedists are probably best equipped to deal with the mechanics of these athletic injuries as they deal with bones and joints, but they fear misdiagnosis or injury to the genitourinary, gastrointestinal, and gynecologic structures.

The athletic trainer or doc would exhaust the use of all those specialists. Each specialist would look at the patient through his/her highly trained spectacles and rule out the various possibilities. After weeks or months without a specific diagnosis, the mystery would continue, and the frustration would grow much worse.

THE EUREKA MOMENT FOR THE CORE

One simple experiment supplied us with new lenses. It satisfied the 3 defining characteristics of an aha! moment: suddenness, joyous screams, and a simple answer. That there was also a painful scream doesn’t change things. The experiment produced a simple answer that showed that the core really did exist and was not just a commercial concept. The experiment led to a whole new way to think about how the body works. It connected the signs and symptoms of many injuries to real anatomy. In this moment, we realized that the concept was really simple. Here’s the story:

I became curious about this anatomy as a busy liver surgeon at Duke University in the mid-1980s. Drs. Frank Bassett6 and William Garrett⁷ had asked me to help with the school’s sports teams, and I saw a number of players whose careers had been cut short by exertional pelvic pain. In medical school, the musculoskeletal anatomy had seemed overwhelming. Armed with the recent memory of physical examinations on 3 athletes who could no longer play, a medical student and I revisited this anatomy in the fresh cadaver laboratory. We were determined to think about function. We could elicit multiple sites of pain around the pubic bones of these athletes.

In the lab, it became obvious that the pubic bone was in the middle of all this activity. It was the hub (Figure 3-7).

Related posts:

Putting It All Together—A Patient’s Perspective on the Core How the Core Universe Forms The Final Stage of Rehab—Getting All the Way Back The Other Muscles—Hip and Core Stability Biomechanics Presenting…the Core!

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