- Speaker #0
Welcome back to The Deep Dive. Today we're tackling a topic that sits right at that intersection of extreme performance and, let's say, very specialized rehabilitation. We're talking about chronic pain, specifically pubalgia, which is just, it's the bane of so many professional careers.
- Speaker #1
Especially in football. It's an infamous issue, really. Yeah. And you came to us with this curiosity about the high-performance rehab protocols for it. We're looking at insights from a scientific interview with Caroline Berger de Femini. who's a STOTT Pilates specialist. And it really just flips the script on how we look at this injury.
- Speaker #0
Which is so fascinating because we're not just looking at standard physical therapy. We're talking about, you know, a biomechanical reorganization. And it's done using these highly specific apparatus like the reformer and the Cadillac. So our mission today is to really unpack why pubalgia isn't just a simple torn muscle, but more of a systemic failure of coordination.
- Speaker #1
And how these very precise... Low-impact tools are used to rebuild an athlete's fundamental motor control, not just their strength.
- Speaker #0
Right, and I think that's the key. Why precision, not just brute force, is the only way to get a durable return to the pitch.
- Speaker #1
Exactly.
- Speaker #0
Okay, so let's start at the beginning. We hear the term pubalgia thrown around all the time.
- Speaker #1
Right.
- Speaker #0
What exactly is the clinical definition here, and why is it so, so tied to high-level football?
- Speaker #1
Well, pubalgia is, at its core, chronic pain. Right in the inguidopubic region, so think the groin area where your inner thigh meets your lower abdomen. Clinically, it's really a combination problem. You've got tendinous suffering in the adductors, those big inner thigh muscles, and that's coupled with an overwork of the lower abdominal muscle insertions, all happening right around the pubic symphysis.
- Speaker #0
And the pubic symphysis, just to be clear for everyone, that's the cartilage joint right at the front and center of the pelvis. So it's a major structural tension point.
- Speaker #1
It is the conflict zone. And in football, the whole syndrome is just emblematic of this huge neuromuscular and mechanical imbalance.
- Speaker #0
An imbalance between what and what?
- Speaker #1
You've got this massive descending pulling force from the powerful adductors.
- Speaker #0
The ones you use to run and cut?
- Speaker #1
Right. And that force is basically in a battle with the ascending stabilizing force from your abdominal muscles.
- Speaker #0
So it's literally a tug of war across that tiny sensitive joint and football just pushes it past its breaking point.
- Speaker #1
Absolutely. Just think about the actions. You've got sudden acceleration, you've got these rapid changes of direction, the chopping motion, and powerful repeated strikes on the ball.
- Speaker #0
All on unstable turf a lot of the time.
- Speaker #1
Exactly. And all of that subjects the pelvis to these immense asymmetrical shearing and rotational forces.
- Speaker #0
It sounds like it's trying to pull the pelvis apart.
- Speaker #1
It is. And this is the real aha moment from the source material. The chronic pain that results isn't just evidence of a muscle tear. It's much more profound. It's evidence of a coordination defect. The body's whole stabilizing system is failing to communicate properly under stress.
- Speaker #0
So the root cause isn't the muscle, it's the system. It's a systemic disorganization that changes the entire approach to rehab.
- Speaker #1
It changes everything. We're talking about a failure in the operating system, not just a broken piece of hardware.
- Speaker #0
OK, so if the pain is a symptom of a coordination defect, then the rehab has to focus on rebuilding that central coordinating structure, the core. This is where Pilates comes in. How does the system specifically address that disorganization?
- Speaker #1
First, we had to define the core functionally, not just as, you know, six-pack abs.
- Speaker #0
Right.
- Speaker #1
It's an integrative structure. It's made of four key players. The transverse abdominus, the pelvic floor, the diaphragm, and the lumbar multifidi. This synergy creates this dynamic corset that stabilizes the pelvis before any big movement even happens. It's like a suspension bridge for your spine.
- Speaker #0
A well-tuned one, ideally.
- Speaker #1
A well-tuned one. But in a player with pubalgia, that system is desynchronized. The transverse abdominis, which should fire first, activates too late. The pelvic floor is compensating torally. The breathing pattern gets really rigid.
- Speaker #0
The whole system is misfiring.
- Speaker #1
Complete.
- Speaker #0
So my first question, and I'm sure a lot of people are thinking this, is if you have an elite athlete, why are you putting them on a low-impact reformer? Why aren't you just loading them up with heavy weights to strengthen those adductors? Doesn't this slow things down?
- Speaker #1
That is the most important question, and it gets right to the heart of the misunderstanding. The goal isn't hypertrophy. It's not about making muscles bigger. The goal is to restore fine neuromuscular coordination. If you throw heavy weights at a system that's already poorly organized, you just reinforce the faulty movement pattern that caused the injury. You actually increase the sheer force.
- Speaker #0
You're training the nervous system before you train the muscle.
- Speaker #1
Precisely. Pilates restores that synchronization by focusing on three things together, respiration, posture, and precise motor control. And the source material points to one specific technique they use on all the equipment, teaching the footballer to dissociate movement from stability.
- Speaker #0
Break that down. What does that mean in practice?
- Speaker #1
So on the Reformer, for example, the legs are moving the springs, creating resistance, kind of mimicking kicking or running. But the whole time, the pelvis, the core of the powerhouse, has to stay absolutely neutral, stable. This requires constant, subtle work from those deep core stabilizers.
- Speaker #0
And that, combined with a specific kind of breathing, is what reduces those dangerous shearing forces.
- Speaker #1
Yes. That pelvic neutrality combined with lateral thoracic breathing actively reduces the stress on the symphysis while the limb is working hard.
- Speaker #0
That has to be a huge mental shift for an athlete who's just used to pushing through pain, focusing only on power.
- Speaker #1
It's a complete overhaul. And that brings us perfectly to the next point, which the source material really emphasizes, eccentric training.
- Speaker #0
The controlled lengthening of the muscle. Why is eccentric work the physiological priority here?
- Speaker #1
Because eccentrics are, simply put, the most effective way to restore a muscle's main job in sports, which is to absorb mechanical energy.
- Speaker #0
To act as a brake.
- Speaker #1
Exactly, to act as a brake or a damper. When a footballer stops suddenly or plants their leg to kick a ball, their adductors have to control their own lengthening under massive tension. They're sophisticated shock absorbers.
- Speaker #0
And if they can't do that properly, that's where the injury happens.
- Speaker #1
That's where it happens. Physiologically, these eccentric exercises, they stimulate better fiber repair, they help align the basic units of the muscle fiber, and they reinforce the connective tissue itself. you're building more resilient tissue.
- Speaker #0
And how does something like the Reformer help with that process specifically?
- Speaker #1
It's all about controlling the resistance. The spring tension is set very particularly to ensure a slow return, ideally about three seconds for that eccentric or lengthening phase. And that slow tempo is critical. It optimizes recruitment of the slow twitch and intermediate muscle fibers, and it stops the athlete from defaulting to those explosive compensatory patterns that just make the pain worse.
- Speaker #0
So you're rebuilding muscle quality and control, not just raw power, by working at a speed the nervous system can actually learn from.
- Speaker #1
The neuromuscular goal is achieving the precision of force. It's slow, it's controlled, and it gives constant feedback, both physical and visual. It's a powerful form of sensorimotor learning. We are literally rewriting the central command in the brain.
- Speaker #0
So let's talk about the tools, because Pilates has this whole arsenal of equipment. The reformer, the Cadillac, the chair, the barrel. How does a specialist use this whole array to structure the rehab for a player?
- Speaker #1
It follows a really logical progression. It moves from horizontal, non-weight-bearing work up to complex vertical stability challenges. Mat work is always the foundation. Just basic body awareness, breathing, finding that neutral spine. Then the reformer introduces that controlled eccentric resistance we just talked about.
- Speaker #0
And then you get to the Cadillac, which, let's be honest, looks pretty intimidating with all its springs and bars. What's its specific role?
- Speaker #1
The Cadillac is absolutely crucial for decompression and restoring mobility without pain. It's all about providing suspension and segmental dissociation. So using the leg springs while lying down a non-weight-bearing position lets the athlete work through their full hip range of motion without any of the compression or impact that would trigger pain.
- Speaker #0
That must be a massive relief for an inflamed joint.
- Speaker #1
An incredible relief. It helps detone those chronically tight muzzles, like the fessas. that are always pulling on the pelvis, it helps break that protective locking pattern.
- Speaker #0
And once that mobility starts coming back?
- Speaker #1
That's where the chair comes in. It's the transition piece. It verticalizes the movement, forcing the player to train stability under load in positions that are much closer to standing or running.
- Speaker #0
And the barrel?
- Speaker #1
The barrel is for three-dimensional mobility and myofascial flexibility. That convex shape is perfect for active, controlled stretching of the entire posterior and lateral chains, the glutes, the hamstrings, the adductors. It improves the whole system's compliance.
- Speaker #0
It really sounds like every piece of equipment has a very specific, non-redundant job. Okay, let's pivot from the machinery to what the source calls the soft skills, breathing and player education. Why is breathing so fundamental to this recovery?
- Speaker #1
Because respiration is the direct link between our mechanics and our nervous system. The diaphragm and the pelvic floor are designed to work in perfect sync to regulate intra-abdominal pressure. But if a player resorts to rigid, shallow breathing from their shoulders, that whole stabilizing dialogue just breaks. Pressure isn't managed, the pelvis has to compensate, the adductors tighten up defensively, and the pain cycle just gets worse.
- Speaker #0
So teaching them proper lateral thoracic breathing is in a way a neurological pain management strategy.
- Speaker #1
It's a critical reset button. It restores mobility to the diaphragm, and neurophysiologically it actually decreases the hyper-excitability of the sensory organs in your muscles. It promotes a parasympathetic state.
- Speaker #0
So you're using the breath to shift the body out of fight or flight and into a repair mode.
- Speaker #1
You're calming the central nervous system down. which is essential for tissue recovery.
- Speaker #0
And what about the education piece? I mean, these are elite athletes driven by instinct. Do they really buy into becoming this actor in their own rehab, learning to self-regulate?
- Speaker #1
They have to if they want a long career. The player has to understand the why. You explain the biomechanics, you show them the sheer forces, and you give them constant visual feedback. You film them on the reformer.
- Speaker #0
So they can see the coordination defect themselves.
- Speaker #1
They see it in real time. They see their pelvis wobble. They see their breath lock up. And that's when the cognitive light bulb goes on. Pilates becomes a school of self-regulation. They learn when to break, when to breathe, when to slow down. That body awareness becomes their best prevention tool.
- Speaker #0
So how does this very specialized approach fit in with the rest of the medical team, the physios, the doctors, the stroth coaches? How do they all work together to get an athlete back on the field?
- Speaker #1
It has to be a highly multidisciplinary approach. The Pilates specialist really works in that functional phase motor skill reintegration, deep postural control. They're complementing the physio, who handles the acute pain, and the physical preparator, who handles the final transition back to high-end performance. They have to share a language. Talking about pelvic neutrality, eccentric timing, it has to be a coherent continuum of care.
- Speaker #0
That communication must be absolutely critical.
- Speaker #1
It is. And the program itself has to be highly individualized. You have to think about the player's position. A central defender needs incredible isometric strength. A winger needs eccentric speed. The equipment's modularity lets you tailor everything. Resistance, velocity, planes of movement do their specific job on the field.
- Speaker #0
So after all this work, what are the concrete criteria? What has to happen before an athlete is cleared to return to competition?
- Speaker #1
There are three critical levels of validation that all have to be met. First is the clinical level. That's simple. Absence of pain, or at least stable, minimal pain. Negative strength tests, painless palpation of the symphysis.
- Speaker #0
Okay, second is functional.
- Speaker #1
The functional criteria. This is proof of stability under high demand. Can they hold their pelvis stable in a single leg stance? Is their movement controlled during simulated changes of direction? Is their hip range of motion symmetrical?
- Speaker #0
And the third, tying it all back to that core idea of organization.
- Speaker #1
That's the neuromuscular criteria. You need to see fluidity of movement and crucially, The ability to maintain free thoracic respiration during maximal effort. If a player holds their breath under load, the coordination defect is still there.
- Speaker #0
And once they're back, what about prevention?
- Speaker #1
Consistency beats intensity every time. Two short 20-minute sessions a week is usually enough to maintain that core.
