I have a patient in my head as I write this. She’d been doing core work for years. Planks, Pilates, all of it. Came in with back pain that just wouldn’t quit despite doing everything “right” or so she thought. Within the first ten minutes of her assessment it was clear that her outer abs were working overtime and her deep core was barely showing up to the party.
You might be surprised how common this is.
The core most people ignore
Here’s the thing nobody tells you about core training: the muscle everyone focuses on, the six pack muscles, is actually the least important part of the stability equation. The core that matters for pain is the inner unit. Four parts working together: your diaphragm on top, your pelvic floor on the bottom, your deep spinal muscles at the back, and your deep abdominals wrapping around the front.
This system is supposed to fire automatically, before you move, before load hits your spine, doing its job in the background without you ever thinking about it. It doesn’t need to look impressive. It needs to be coordinated and responsive. In most people I see dealing with chronic pain, it isn’t either of those things.
What happens when it checks out
When the deep core stops doing its job, your body doesn’t just fall apart. It’s smarter than that. The big outer muscles step in and try to create the stability the deep system should be providing. They brace. They grip. They work constantly in ways they were never designed to.
The result is a body that feels constantly tight and perpetually one wrong movement away from a flare up. Stretching helps for a day. A massage feels amazing and then wears off. Nothing sticks because nobody is addressing the actual problem. That’s the cycle I see broken again and again once we actually train the right system.
What actually fixes it
I’ll be honest. Retraining the deep core is not exciting to watch. There are no impressive weights involved. Sometimes it looks like lying on a table learning how to breathe correctly. Patients occasionally give me a look that says “this is it?” And then three weeks later they tell me their back hasn’t felt this good in years.
Starting from the inside out, finding the pelvic floor, the deep abdominals, the breathing pattern, before adding any real load or challenge is the piece most core programs completely skip. It’s less dramatic than a hard ab workout. It’s also the thing that actually changes pain.
If you’ve been doing the work and still hurting, the problem probably isn’t your effort. It’s where you’re directing it.
Dr. Rachel Atufunwa PT, DPT