I’m a girl who loves fashion. I’m such a Cinderella [Figure 9-1] — I love to put on a great dress and heels. It’s fun!
—Maria Bello, American actress and writer, from Norristown, Pennsylvania.
NOT ALWAYS MINOR STRAINS
It was just a minor strain. Nothing serious.
The Washington Nationals’ Ryan Zimmerman’s rectus abdominis tweak during 2011 spring training wasn’t supposed to be anything it all. Until it was.
While diving back into second base during the first week of the regular season, Zimmerman did more than just aggravate the area. He tore it up. After a month of treatment and some rest, Zimmerman was still in enough pain that in mid-May of that year, surgeons repaired the tear.1
Figure 9-1. Cinderella.
Figure 9-2. (A) Artist’s depiction of the rectus abdominis muscle. (B) Prominent rectus abdominis in a male model.
Most people know the rectus abdominis as the muscle group that comprises the 6-pack (Figure 9-2). Athletes like to have nice abs, but they would rather have a collection of rectus abdominis muscles that allows them to lunge, spike, dive, pull, and perform a menu of other important functions that involve extending the body. Zimmerman returned to action and has enjoyed good health since. But there is no guarantee someone who plays baseball’s hot corner and is constantly diving to stop hard-hit balls will be pain-free forever.
And he has plenty of company.
He had torn the muscle from the pubic plate (ie, the cover of the pubic baseball; see Figures 8-4 and 8-5). The muscle had twanged upward, and the bleeding end caused a big, proximal hematoma.
Yes, most rectus abdominis strains have no bad consequences. But you had better keep your eyes open for the more serious injuries. Put up your antennae for anything unusual or if pain lasts more than a few days. These injuries can be serious and debilitating. With precise diagnosis and treatment, nearly all are highly fixable (Figure 9-3).
COMMON THEMES
From our clinical practice, we have quite a number of other illustrative cases from whom we could have chosen to lead off this chapter. Dramatic cases of the rectus abdominis ripping off the pubic bone affect various types of athletes and everyday folks, from bull riders to P90X beginners. You may have seen the famous ESPN video of the wonderful role model in baseball Nomar Garciaparra falling to his knees in pain while sprinting out of the batter’s box, or know about a star for Manchester United who suddenly reeled to the ground in pain at a key time in the match. Or perhaps you heard about Jack Sock, the American tennis prodigy with the huge serve, who had such troubles with his abdomen early in his career.
You probably don’t know about the young woman from Philadelphia who tore off her abdominal muscle picking up 2 cases of beer, or the 20 soldiers with badly wrenched rectus abdominis muscles after a sit-up contest at a US Army base. We have a lot of such stories. The point is that abdominal muscle injuries happen every day in athletics and routine life. Some of them get better and some of them don’t.
So, what might the folks with severe injuries have in common predisposing them to such problems? One main thing: they work their abdomens out way too hard. They might do this voluntarily (eg, novice exercise enthusiasts getting back into shape, pitchers doing inverted sit-ups in off-season workouts) or they might be in situations in life where they have to work their abdomens too hard (eg, volleyball players, dancers, divers). Beyond a doubt, the same repetitive forces to the rectus abdominis muscles may have a serious toll; often, they cause enough wear-and-tear to predispose you to something bad.
Figure 9-3. Rectus abdominis hematoma from pubic plate injury. The muscle of this major league third baseman had torn off the plate 6 weeks previously and the proximal muscle stump bled into the substance of the muscle. (A) Coronal stir image of a well-organized hematoma several inches above the plate. (B) T2 sagittal image showing the tract to the same hematoma from where the muscle ripped off the plate.
You can probably easily guess what sports or what specific positions within sports would make someone most vulnerable to isolated rectus abdominis avulsions. Think about it? The rectus abdominis primarily flexes the abdomen with the chest.
Pick sports or positions that involve a lot of flexion and extension. You’ve got it—tennis players with big serves, third basemen, rowers, bull-riders… The list goes on. Of course, you can get these tears in most sports. The point is that certain activities make you more susceptible to these specific injuries. And when it comes to abs, most people who try to stay in shape mistreat them. The soldiers mentioned previously are supreme examples.
We like to call the rectus abdominis the “Cinderella muscle” because it is regarded as so beautiful yet wicked stepsisters love to abuse it.
WHAT’S OBVIOUS ABOUT THIS MUSCLE
The rectus abdominis is probably the most important of our core muscles.
It may not be the strongest. But it is so important for balance and athleticism. It connects the upper body to the lower body, it directs the mechanism that harnesses our core power and even seems to have a direct connection to the brain. It is beautiful, humble, and underappreciated. While the world may recognize its beauty, it may not appreciate its graciousness or importance. That’s why the world regularly abuses the rectus abdominis muscle.
Figure 9-3 exhibits some subtle details about the rectus abdominis muscle. At the top end, it intermingles with the rib cage. On the sides, it merges with the obliques, and at the bottom, it joins with the pubic plate, which attaches to the pubic bone and rest of the harness. It forms the top part of the harness.
Think of the rectus abdominis as having 3 parts:
- The top part where it merges with the ribs
- The middle part, which becomes hugely important in some sports (eg, diving, tennis, gymnastics)
- The bottom part, a key part, the connector to the thighs
In most but not all sports, the bottom part puts in the most work. Think about soccer and American football. On the other hand, rowing works more the top part.
It was upon the untimely death of this good man, however, that the stepmother’s true nature was revealed: cold, cruel, and bitterly jealous of Cinderella’s charm and beauty, she was grimly determined to forward the interests of her own two awkward daughters. Thus, as time went by, the chateau fell into disrepair, for the family fortunes were squandered upon the vain and selfish stepsisters while Cinderella was abused, humiliated, and finally forced to become a servant in her own house. And yet, through it all, Cinderella remained ever gentle and kind, for with each dawn she found new hope that someday her dreams of happiness would come true.
—Giambattista Basile, Pentamerone (1634) and Grimms’ Fairy Tales (1812)
WHY CINDERELLA?
The word Cinderella has, by analogy, come to mean one whose attributes were unrecognized, and who unexpectedly achieves recognition or success after a period of neglect. So it is for the rectus abdominis muscle. It is time for that muscle to shine. Of course, Cinderella was beautiful, but we are talking about the way she was abused. If that abuse continued, she would eventually lose her beauty. Fortunately, she became recognized for her strengths—and was saved.
Of course, we all know the rectus abdominis is beautiful. “Six-pack abs” dominate the fitness culture—“30 Days to 6-Pack Abs,” “The 6 Best Exercises for 6-Pack Abs,” blah, blah, blah.2 Look at Figure 9-2B. Beautiful? Yes. Subject to abuse? For sure.
Look a little closer and notice that the 6-pack doesn’t really start until about the level of the belly button. Do you think that is by chance? Note the absence of folds below the belly button. There are purposes for these subtleties of our anatomy. We don’t know all the reasons for the subtleties yet, but we are learning a lot of important stuff. The likely reason for the relative absence of folds below the umbilicus probably has something to do with this being the top part of the core’s harness. Think about what happens in a sit-up. You use the lower half of the abdomen more the lower your upper body gets to the floor. You need that part of the abdomen to flatten out. As you reach the top of the sit-up, your head and chest bend so much more, creating an anatomic “need” for folds.
The rectus abdominis muscle has many subtleties. Few people appreciate them. For that matter, few people appreciate the muscle as a whole; we abuse it.
This story is about the Cinderella muscle of the core. It is important. It is gracious. We must treat it gently and with respect. Otherwise, we will lose it. Just like the first moral of the story Cinderella: think of beauty as a treasure but graciousness as priceless. Without it, nothing is possible; with it, one can do anything.
The fitness world focuses on 6-pack abs, making these sit-up muscles more beautiful. The world believes the more sit-ups one does, the more rectus abdominis exercises one does, the more beautiful these abs become. What the world does not recognize is all the wear and tear all this work causes and the injuries to which this subjects this muscle. The fitness world—personal fitness instructors, the sports world, even the military—does not come close to grasping how much damage this continual abuse causes.
The massive number of sit-ups recommended by “fitness experts,” the ab exercise machines out there, fitness magazines with all the pictures, they all feed a culture of lust, greed, ignorance, and abuse of this muscle. If you come away with one theme from this book, come away with this theme: Lust may be okay, so long as you protect the rectus abdominis muscle.
We must protect our Cinderella.
THE WAY IT WAS
The rectus abdominis muscle belongs to no medical specialty. If one had to identify a medical specialist that “owns” or knows most about this muscle, it would be the general surgeon. But the general surgeon’s knowledge base concerning this muscle is shallow. For years, surgeons only viewed it as part of the abdominal wall that holds in the guts. They debated such “important” things as whether it is better to cut across it transversely or vertically, and of course, that great medical mystery was never solved.
General surgeons never talked about the importance or function of this muscle in terms of fitness or health. The general surgeon considers the muscle with respect to the occurrence of certain types of hernias, defined as protrusions through the abdominal wall. They pay attention to the occasional tumors that occur here, particularly ones that need to be cut out, like desmoids and the more aggressive sarcomas. The fact remains: General surgeons, and basically all medical specialists for that matter, think of the rectus abdominis muscle merely as one of the muscles that keeps the insides of the belly from falling out. That’s it.
THE WAY IT IS
So, you’ve already heard the Cinderella story. Think of the rectus abdominis muscle as amazing, that it does so, so much and that it is so, so beautiful. And that we still have so much more to learn about it.
Anatomically, the muscle is quite variable—sometimes having 2 heads in its distal aspect and sometimes 3, and sometimes associated distally with another muscle called the pyramidalis (see Figure 7-13). The rectus abdominis joins with the ribs in complex ways. It does such subtle things as house certain intercostal sensory nerve branches that can cause great pain. The muscle provides astonishing coil and spring that fits well for jumping, extending, and flexing. Think of its function for divers, gymnasts, and ballet dancers.
The muscle is so important in the harness mechanism. It provides some strength, but not nearly as much for which it is given credit, but directs the power from all the muscle adjacent to it, like the side and back muscles. It harnesses the strength from those muscles so that we use it efficiently. In a sense, it also provides both the bridle and the harness for control of this strength. This muscle is super important for the harness/“pubic joint” concept. It is also the great communicator for the core to the brain in matters of athletic activity. Think about it. If you are sprinting hard and want to suddenly shift to the right or left, what muscles does your brain first ask to tense up first? No doubt it is the rectus abdominis, and then the brain asks it to coordinate with the rest of the harness mechanism and the adductors. MRIs show that the rectus abdominis also quickly atrophies in response to injury or nonuse. The latter fact provides added testimony and circumstantial evidence for how much we ordinarily use this muscle and how truly important it is.
Add to this knowledge base that this muscle is easily injured from overuse or too much force, usually from abdominal hyper-extension or thigh hyper-abduction.
Because of its intimate relationship to the pubic bone and thighs, we have seen multiple problems related to the rectus abdominis muscle. Most commonly, the problems occur in association with adjacent bony and muscular structures. For now, let’s consider some of the syndromes that we have identified that are just relatively isolated to the rectus abdominis muscle.
Rectus Abdominis Atrophy
We see this so commonly now on the side of primary injury. The presumption is that the lack of connection to the pubic plate or pain, or both, leads to avoidance of using the muscle. Atrophy is a regular finding with mesh used in hernia repairs. Somehow, the mesh fibroses and fixates the underlying or overlying muscle rendering it less mobile or functional. There is debate about whether the dominant or nondominant side houses the bigger rectus abdominis in upper extremity–dominant sports, such as baseball or tennis. One paper attests to the nondominant side being bigger in tennis players.3 We have seen dramatic differences in rectus abdominis size in athletes, but in a much more unpredictable fashion than that paper would suggest. And in our clinical experience, the dominant side seems to be larger, except when there is an injury (Figure 9-4).
Figure 9-4. Rectus abdominis atrophy in a 24-year-old professional soccer player with right adductor pain. We speculate that abdominal detachment was the primary event leading to pubic plate separation and adductor injury. This fat-sensitive MRI image shows atrophy and fatty replacement of the right lower rectus abdominis muscle.
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