Ready…set…Are you ready to go? This short chapter may be the most important one in the book. It introduces an essential concept for understanding the core. One might say the central concept. Dare we say the “core” concept? Sorry, we are blabbering again.
We have now established the pubic bone as the center of our body’s universe. There is no doubt this is so. That’s the anatomy. It is what it is. Copernicus, da Vinci, Belichick, and Krzyzewski all agree. Now we shall show how the center unites the body. We shall reveal how we control and optimally harmonize our power muscles (Figure 8-1).
Figure 8-1.
The chapter is short, so no excuses… you must read it.
THE SECRET TO ATHLETICISM
To begin, think about what goes on in the core of a bucking bronco rider.
Then think about how an injury of the core may humble some of the most courageous and robust sports heroes in the world, sometimes in the biggest games of their lives (Figure 8-2).1
Figure 8-2. Nomar Garciaparra humbled by a groin injury that downed him taking a first step out of the batter’s box. (Reprinted with permission from AP Photo/Kyle Ericson.)
Athleticism is all about the pubic bone and the muscle harness. This part of the body, which we shall describe in detail, is the foremost dynamic area that determines the ability to stay on the horse or in the game. Of course, strength is important, too. The harness controls that strength. This harness is the main apparatus that manages the power. The harness also must communicate directly with the brain and then transmit directive messages to the torso and extremities. As you think through the analogy, keep in mind that our intact muscular harness also serves, in part, as our body’s reins and bridle. Think of reins and bridles as things we also use to skillfully restrain, distribute, or liberate our power, or a horse’s power, for that matter. Do not get confused about all this. Do not stick to any presupposed, strict interpretation of the word harness. Think of it as a controlling mechanism.
Figure 8-3 is a frontal shot of the main musculoskeletal anatomy involved.
Figure 8-3. A view of the core’s third part—the musculoskeletal core—from the front.
HOW THE HARNESS WORKS OR MALFUNCTIONS
Remember the baseball from the last chapter. That visual illustrates the basics about how the harness works. Think of the thick fibrocartilage that surrounds both pubic symphyses and then extends more thinly onto the rami as the “cover” to a baseball. The fibrocartilage cover of the pubic bone connects with the 4 main muscular structures on each side. The spongy fibrocartilage cushions tremendous forces, as the harness directs power muscles and all the rest of the anatomy to twist, turn, and perform so many other feats. (See Figure 8-4.)
Now think about how this precious harness might malfunction. Muscles may tear. Muscles may rip right off. This injury causes a reapportionment of forces (ie, an imbalance). The remaining intact muscles “over-pull” (compensate), and a tug of war on the “baseball cover” ensues. Imagine the numerous varieties of injuries that might, and do, occur to this apparatus. Any of the muscles may tear, tears may happen proximal or distal along their lengths, or multiple muscles may sequentially tear because of changes in forces and tension. Most athletic injuries happen from “the outside.” What we mean by that is illustrated by the following type of “inside” injury to the harness apparatus. Think about what happens when a big baby delivers through too narrow a birth canal. The baseball (pubic bone) splits “in half” (ie, the pubic symphyseal joint separates) from huge internal forces.
Figure 8-4.
Figure 8-5. Note the core’s fantasy baseball looks the same as the one above, except now the baseball’s cover has become loose. The graphic does not show any muscular injury, but does illustrate vividly the main purpose of this analogy. The result of the tug of war of asymmetric forces is that seams untie and the cover loosens. This happens to the pubic bone in real life. A muscular injury initiates an imbalance of the pulls on the fibrocartilage cover. The tug of war results in separation of the cover.
Figure 8-5 portrays a fibrocartilage pubic plate separation. This is anatomically identical to the cover coming off a baseball. Okay, it is not exactly the same, but you get the picture. Fluid builds up between the pubic cover and bone, an analogous space represented by the baseball picture. For years, clinicians didn’t realize what was really happening and were calling that fluid, plus the associated bone marrow edema (fluid that crosses the cortex), osteitis. Think of this term as vague; all the term really defines is any kind of inflammation in or around the pubic bone.
In the past, osteitis was felt to be its own process,2,3 with its own pathophysiology solely affecting this bone. That is not accurate. That is not what happens. Osteitis is a reactive pathologic process and generally results from harness muscle injury. The injury produces weakness at one of the muscular attachment sites, and that weakness in turn causes unopposed, compensatory muscular contraction at the other 3 main muscular attachment sites. That imbalance that the forces generate results in a functional tug-of-war on the fibrocartilage plate cover, which then ends up separating from the underlying bone (Figure 8-6). Just like the baseball you left outside overnight!
A rational parallel is to the anterior cruciate of the knee. That midline structure does not heal on its own. One can build up the hamstrings and quads and make up for some of the resultant knee stability, yet the knee continues to give way during extremes of exertion.
Figure 8-7 shows the core muscular injury process that leads to “osteitis.” Injury to one of the key core muscles causes other muscles of the harness to over-pull. The compensatory tugs on the fibrocartilage plate lead to the plate separation.
Figure 8-6. MRI of normal and injured pubic plates. (A) Normal pubic bone and plate. The arrows indicate the dark fibrocartilage pubic cover on the superior surface of the pubic bone. The arrowheads point to the pubic bone. Note the absence of whiteness between the plate and the bone. (B) Severe separation of the pubic plate. The arrowheads designate fluid in the crevices between bone and fibrocartilage. The arrow indicates bone marrow edema inside the pubic bone. The actual muscular injuries are barely seen. Intact, this harness apparatus works in concert with the brain and directs and modulates the body’s power. Disrupted, the apparatus instigates problems. The loose cover slides involuntarily. Body weight forces the cover to slip. The midline becomes unstable. Building up the power muscles sometimes minimizes that instability.
Figure 8-7. This diagram shows schematically what is going on in Figure 8-6B. A right rectus abdominis injury triggers compensatory pulling by the other muscular attachments and eventual separation of the pubic plate, represented by the wider layer of whiteness on the right side (ie, between the gray fibrocartilage and the paler bone). So far, the plate separation (ie, “osteitis”) process just affects the right side. With time, the left side gets involved.
A “CRIPPLING” INJURY
The following set of MRIs shows quite graphically an example of such an injury.
Figure 8-8 shows the pubic bone losing its cover. This NFL football player had been hurting for a month. During a playoff game, he initially played in agony; then he suddenly toppled over in so much pain that he could not continue.
Now look at more of that patient’s MRI images (Figure 8-9).
This NFL star had a severe plate separation injury, beginning with a right-sided harness issue. It progressed to involve the other side. He played with it, but had to compensate like mad. He remained effective until almost everything ripped off.
We described this injury as “crippling.” And it was, until it was repaired. Keep in mind also that these injuries are almost always correctable surgically. This patient is now back better than he has ever been before. Even with such a severe injury, he will likely come back and remain the star he always was, or be even better.
Figure 8-8. T1 axial oblique view showing a pubic plate separation (arrow) seemingly worse on the right side but with a hint of missing portion of the plate on the left side. Note the problem is on both sides. Going into the playoff game, more pain and disability emanated from the right side. During the game, something happened, and the ultimately debilitating pain suddenly arose on the left side. See how the cover of the pubic bone is coming off. Fluid, the white between the bone and dark fibrocartilage plate, spreads along the undersurface of the pubic bone. Significant edema exists in both sets of harness adductors.
Figure 8-9. Four additional views of the same injury. Note problems on both sides. (A) Coronal stir image showing the same plate separation fluid as Figure 8-6B, some right-sided pubic plate separation (arrow), plus a big hematoma in the left adductor complex. All the white represents fluid. Note also that some plate disappears below the left pubic bone. The large adductor stump lays about 6 inches distally (arrowhead). (B) T2 sagittal image showing the same missing fibrocartilage at the left pubic bone and the same stump (arrow) shown in A. (C) T2 axial image showing an absent distal rectus abdominis muscle on the left side. (D) The same view 1 cm lower, showing missing plate on the left (arrow). Note the asymmetry compared to the right side and the adductor edema on both sides. Obviously, this is a severe injury.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
