How do we go through all the rest of the core muscles and keep things from getting incredibly boring? Don’t fret. The task turns out to be simple. The rest of the muscles have a common bond; the linkage is stability. Everyone knows, or has seen, people who walk around with incredible pain that seems to reside in the core. Most of the time, the problem does stem from the core.
First, let’s begin with a Freddy Krueger story.VID 1
Then, let us introduce you to Emma.
A LONG ROAD TO HAPPINESS—THE SAGA OF HIP INSTABILITY
In New Zealand, she had been an elite athlete, capable of competing for her country in international competitions in 3 different sports.
And then, she could barely walk.
The car crash was bad enough, although it wasn’t so catastrophic that the police were summoned. The aftermath caused the most trouble. Well, that and the doctors.
Emma had played netball (like basketball without backboards or dribbling) and volleyball and had rowed on age group national teams for her native New Zealand. She wasn’t competing at as high a level in 2013 when the car she was driving was slammed into from behind, but she was active and still training to stay in shape.
“It felt immediately like something had come right through my pelvis from the backseat,” she says of the crash. “It happened so very quickly.”
She wasn’t immobilized. In fact, she exited the car and went about the business of collecting drivers’ licenses and insurance information. Later, the pain started in her hips and throughout other areas of her core (Figure 14-1). And nobody was able to give a definitive diagnosis of what exactly was wrong.
Figure 14-1.
Not that doctors didn’t think they could solve the issue with surgery. Make that surgeries. Emma withstood 3 different procedures, none of which removed the pain and instability that had come to haunt her.
“Some of the doctors were honest and said they didn’t know what the problem was, and others performed surgery and then told me there wasn’t anything else they could do,” Emma says. “A lot of them wouldn’t admit they didn’t know what to do.
“I felt like I was outside the scope of normal treatment. I didn’t fit into any of the traditional boxes that they knew about.”
She had her first hip surgery in May 2014 in Australia and hasn’t been able to work—as a physical therapist and Pilates instructor—since. Things became so difficult for Emma that although she considers herself someone who won’t ever give up, it seemed like the answer would never come. “My hip did not belong to me.”
She says, “I was absolutely distraught. I got to the stage where I could do just one outing a day, and that was it.” She could barely walk. Every step felt like her her pubic bone was falling out.
Soon after Emma discovered a team of health professionals, she began the process of getting better. “They immediately picked up on what the injury was, it was a breath of fresh air,” she says. The key was an overall understanding of the hip and its need for stability and full mobility. It took a combination of several months of intensive physical therapy and surgery. The team eliminated the instability Emma was feeling in her hip. They sewed some muscles together, tightened the ligaments immediately surrounding the hip, and shaved off the residual impingement in the joint so that it would be able to move freely and she would be pain-free and sturdy through her core. She felt some relief immediately after the surgery.
As she moved through the recovery phases, Emma was able to recognize a difference from the previous procedures. This time, she knew the right work had been done.
“My hip feels like it belongs to me again,” she says. “It’s fantastic. Before, it felt like my hip wasn’t part of my body.”
Emma’s story exhibits the saga of hip instability. Patients often have a feeling of complete “loss” of pelvic control. The feeling goes from nipples to knees. No doubt, Emma’s mild hip dysplasia played a role in this.
Her situation became complicated after a core-jolting, rear-end collision and then the hip surgery, which produced even more laxity in her ball and socket. The hip’s ligamentous capsule was involved. Then came problems with more and more other muscles, then the back, and finally gastrointestinal, genitourinary, and gynecologic systems and many other visceral functions. Hip or pelvic instability is often hard for the patient to describe. The instability eventually embroils all 4 parts of the core.
Core instability ignites boundless misery.
YIKES…SEEMS LIKE LOTS OF MUSCLES
Remember that we defined the core as the entire region of the body, from mid-chest to mid-thigh, all inclusive?
That means we have still a lot of other muscles to discuss. Don’t worry. The rest is easy…easy for 2 reasons: (1) because we really don’t know all that much about them, and (2) because in order to understand them, all one has to do is appreciate one basic concept. The basic concept is a fresh look at what we instinctually have understood for a long time, the concept is stability. Stability is probably best understood by grasping whatever it is that we mean to communicate when we say instability. The definition of stability then becomes expressed by this simple Dick and Jane–type formula: Stability = Absence of Instability.
At this point, let us summarize what muscles and other soft tissues we have gone through thus far, and then go over the ones left to cover. So far, we have gone through:
- The harness muscles: The rectus abdominis and 3 adductors. This unit harnesses and directs the huge forces generated by the power muscles. How can you forget the pubic bone, with its baseball-like cover at the center of all this, and the coordination and stabilization it provides for the pelvis and rest of the core?
- The Rodney Dangerfield (rectus femoris) muscle: The lead muscle within the quadriceps mechanism. The underappreciated rectus femoris probably directs and stabilizes the other muscles of the anterior thigh.
- The Eminem (psoas) muscle: This important muscle performs so many functions, many of which remain unstudied and mysterious, such as its role in central core or hip stability. The Slim Shady muscle lies so intimately with the hip and harness muscles.
- The new beauty (gluteal) muscles: These are powerful initiators of core movement as well as important spine/pelvis/hip stabilizers. Judging from their size and power, they likely play crucial roles in proper core function.
In this chapter, we shall chat about most of the rest of the muscles of the core: the tensor fasciae latae (TFL), the deeper posterior pelvic muscles, our back and side muscles, and the “pelvic floor” muscles as defined by the “uro-gynecologists.” At this point, you might be thinking like Elaine from Seinfeld: “Yada, yada, yada.”
We shall also gab about fascia, ligaments, and other “orthopedic-type” soft tissues that reside there. We shall cover the hamstring and some remaining parts of the anatomy in upcoming chapters.
Are you still worried? Do the above seem way too much to cover in one chapter? Don’t worry. This chapter shall be astoundingly concise.
DEFINING STABILITY
Note that in each of the 4 bullet points describing our nicknamed core muscles, we mentioned the word “stability,” yet without definition. If you look carefully within the orthopedic or fitness literature, the same thing happens all the time. Nobody defines the word stability. Rarely, does anybody attempt to define the term. Just about everybody in the fitness world—maybe everyone in the whole world—believes that they understand the concept of stability. Well, we don’t. At least, no accepted definition appears consistently in the literature. The definition of stability remains elusive.
Well, no more. The added bonus: This chapter shall be inordinately brief.
Let’s begin. And try out a definition or two. Let’s start with the term hip instability, and from there, figure out the term stability. Then slog out a definition that applies to the entire core (Table 14-1).
We choose the hip first because this seems anatomically the most simple of all the 4 parts of the core (see Chapter 5). The other 3 parts have zillions of muscles or physiological systems to consider. We have defined the hip, of course, as just the ball and socket—no muscle or other organ systems involved. For simplicity, let’s ignore that little tiny bit of muscle (the ligamentum teres, etc) that resides there.
Okay, got it? Let’s toss up and bat around a fresh definition.
Hip instability: The femoral head ball dislodging enough from its normal position to cause disabling pain during routine activities.
Think about this definition. The femoral head is really what we are talking about it, isn’t it? The “ball” of the ball-and-socket joint is what really matters, not the socket. The acetabulum may be stunted in growth or have other features that contribute to instability, but instability has to be defined by the femoral head and not the acetabulum. Pain also has to be a part of the definition, doesn’t it? Pain can take on various forms. It can be a mild discomfort, pudendal in nature, affecting the compensating other side, etc. Most often, pain takes on a constellation of patterns. Whatever forms it takes, pain must help define instability.
Now let’s examine the third part of the definition—“routine activities.” These cover the daily activities for most of us slouches (eg, walking or sitting, getting up from the couch and going to the refrigerator). The term routine also covers the strenuous activities of an athlete. The bottom line here is that pain with routine activities has to cover all individuals—both us slouches and high-performing athletes. This definition says that with hip instability, the ball of the hip slips abnormally enough out of its normal position to ruin the quality of routine life of any human being, and perhaps other animals.
If we accept that definition, then the corollary definition for hip stability flows easily to mean: “the ball and socket functioning normally.”
How can one argue with such profound logic? If you disagree, then please massage our ego and be courteous enough to read on, anyway!
Now consider how the term instability might apply to the rest of the core. Let’s try out the term instability to mean: dysfunction enough to cause disabling pain during routine activities. Take the pubic bone joint as a test example; dysfunction would apply to the slippage of the fibrocartilaginous “loose baseball” cover during cutting or jumping. For the pubic symphyseal joint, it might mean the 2 sides of the pubic symphysis rubbing against each other. For the back, it might mean 2 vertebral bodies moving as a disc dislodges.
One can go on and on describing different types of core instability (eg, the rectus femoris causing instability of the anterior thigh). No doubt, many types of pelvic instability exist, yet have never been described. Consider all the different mini-joints in the pelvis and the many small parts of bones that reside there connected by large and small ligamentous structures. Also, think about the enormous number of patients in the world with undiagnosed and disabling pelvic pain who sit, over and over again, in the waiting rooms of gynecologic, urologic, and primary care offices.
Let’s end this discussion by defining core instability. Let’s use this extrapolation from what we have just discussed:
Core instability: Any biomechanical dislodgment within the core that causes enough pain during routine activities to interfere with one’s quality of life.
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