Pilates for Weak Hips

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1 Pilates for Weak Hips Jean Callaghan-Hoskins March 2017 Course Location: Trio Life Fitness, Austin TX

2 Abstract This is a case study of a 71-year-old female who was experiencing knee pain and sought physical therapy. The physical therapist diagnosed her with weak hips which was, in large part, causing her knee pain. Many years prior, she had a surgery to fuse the joint in her large toe due to osteoarthritis which led to a change in her gait which ultimately contributed to her weak hips and consequent knee pain. This paper will specifically discuss the anatomy of the hip and how the BASI block system can help strengthen her hip joints as well as realign her anatomic stance and gait.

3 Table of Contents Abstract 1 Table of Contents 2 Anatomy 3 Case Study 5 Body 6 Conclusion 10 Works Cited 11

4 Anatomy The hips are a major body joint, specifically a synovial joint referred to as a ball and socket joint, one of only two of these types of joints in the body. The reason it gets this name is because the ball of the femur fits into the socket of the pelvis as show in figure 1 below. A ball and socket joint can move in many different planes by abducting, adducting, extending, flexing, and torqueing in place. Figure 1 Ball and Socket Joint The hip is a powerhouse joint that allows us to walk, run and jump with power. The ball and socket joint cannot move and stabilize the hip all on its own, it must have some strong accompanying muscles to allow this to occur. There are four major sets of muscles that move the hip in the different major directions (Taylor).

5 Figure 2 Muscles of the Hip The first set of muscles is the anterior muscle group which allows the hip muscle to flex or bend. The anterior muscles are made up of the psoas, iliacus, rectus femoris, sartorius, and vastus muscle group (Taylor). The second set of muscles is the posterior muscle group which is used in extension of the hip which straightens out the leg posteriorly and propels forward. This muscle group helps us to walk, run, climb, etc. The posterior muscle group is made up of gluteus maximus and the hamstring muscles which consist of the bicep femoris, semimembranosis and semitendinosus (Taylor). The third group is the abductor muscles of the hip joint which moves the hip away from the midline of the body to induce lateral movements such as initiation of stepping sideways. The muscles that make up this group are the piriformis, the gemelli, tensor fasciae latae, sartorius and gluteus medius and minimus muscles (Taylor). The final group that helps in movement of the hip muscle are the adductor muscles which move the inner thighs together such as in lateral movements. These muscles are made up of the

6 adductor longus, magnus and brevis group as well as the pectineus, and gracilis muscles (Taylor). The ball and socket joint combined with the powerful muscles of the hip help make this body part a powerhouse group. The hips are truly instrumental in many key components of our body movements, which is why Pilates dedicates a portion of their exercise regimen specifically to the hips.

7 Case Study A 71-year-old client, Jane, has knee pain that is affecting her quality of life. Several years ago, due to arthritis in Jane s right first metatarsal phalangeal (MTP) joint she had a fusion of this joint. Subsequently, Jane s gait changed because she could not bend her first MTP joint the same way, though she initially had no right knee pain. As time went on, she began to have new right knee pain and she started working out with a personal trainer at the gym. This helped temporarily, but eventually her knee began to swell and the pain became unbearable which caused her to stop working out completely. Due to the ever-increasing lack of mobility and pain, Jane was referred to a physical therapist. After the assessment, the physical therapist determined that her knee pain was due in a large part to weak hip muscles. After Jane completed 6 weeks of sessions with the physical therapist, she was still not ready to get back into the gym. That is when Jane reached out to me to begin Pilates. After my initial assessment, I agreed that a key area she had to work on was hip muscle strength in addition to proprioception and balance. She also has overall weak core strength. One additional thing I observed in my assessment was that Jane has one leg slightly shorter than the other; this not only affects gait, but also her back and shoulder alignment. Finally, Jane has history of a prolapsed uterus which I felt I needed to take into account for her sessions. Before we really started getting into the meat of the BASI block system, Jane and I spent some time on body movement and proprioception because without awareness, little can be achieved (Isacowitz, 2014, p. 6). After working on these key segments, we worked on breathing exercises since these promote natural movement and [are]the first step to educating the neuromuscular system (Isacowitz, 2014, p. 7). I also explained to her how the abdominals, diaphragm, back muscles and pelvic floor create the internal support system (ISS), powerhouse,

8 or body core and how engaging this group during exercise will help with more efficient movement. (p. 18). I recommended that Jane would benefit from dedicated private sessions 2 to 3 times a week. She kept up with this routine fairly well, although she had many physical set-backs over her sessions (mild illnesses and pain) and we weren t able to progress much past beginner. Despite these physical set-backs, Jane reported that she loved how she felt and had a new-found respect for Pilates and that she wants all of her friends to sign up. Warm-up on the mat Pelvic Curl Spine Twist Chest Lift Chest Lift with Rotation BASI Block System This warm-up series allowed Jane to gently warm up her ISS. Foot Work on the reformer Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V- Position Toes Calf Raisers Prancer Single Leg Heel Single Leg Toes Reformer foot work is great for strengthening knee and hip extensors, which is perfect for Jane. We had to really focus on proper alignment and movement awareness. She had a tendency to hyperextend her left knee (contralateral to the pain) while pushing the carriage away.

9 We also had to work on distributing the weight evenly over both feet as oftentimes Jane would turn one or both feet out; she was instructed and prompted consistently to engage her adductor muscles and evenly distribute the weight. Finally, since Jane had a fused right first MTP joint, it was difficult for her to plantarflex her foot; unfortunately, she was not able to achieve full range of motion of this ankle, but she did it to her tolerance and ability. We really worked on correct alignment while doing this exercise series. Hundred Prep on the Reformer Hundred Prep When I met Jane, she had very little abdominal or back strength. A simple chest lift was extremely difficult for her. She avoided any abdominal exercises for many years because of her known prolapsed uterus. She was worried that it would worsen while performing any abdominal exercise. We worked specifically on engaging her pelvic floor while engaging abdominal muscles. As time progressed, Jane improved greatly. Currently, Jane is able to maintain her legs in proper table top position and perform a chest lift while engaging the pelvic floor. Hip Work on the Reformer Frog Hip Circle Down Hip Circle Up Hip Opening During these exercises, Jane had to engage ISS, keep her pelvis stable and heels together while engaging her inner thighs in order to avoid inciting pain in her knees. These exercises were crucial for her since these hip exercises work on all aspects of the hips muscles that Jane really needs.

10 *Please note that spinal articulation and full body integration were too advanced for this client to attempt during these sessions. Instead, we did spinal articulation exercises on the mat for her to start practicing the initiation of movement. Stretches on the Reformer Standing lunge This was a great exercise for Jane to target her hamstrings and hip flexors. Due to her knee pain, I put extra padding on the carriage under her knees to help cushion. Jane was fairly flexible and I had to really watch her shoulders and her pelvis since she tended to lift one side up. Arm Work on the Reformer *All exercises in the supine position Shoulder extension Shoulder adduction Arm circle up Arm circle down Triceps This obviously not only helps with her shoulders, triceps and latissimus dorsi, but also helps with stabilizing the scapula and trunk. Jane really struggled with trunk stabilization, but she is well on her way to advancement into intermediate arm work. Leg Work on the Cadillac Squat This was a perfect exercise for Jane. Prior to beginning Pilates, Jane s squat form instruction and knowledge was completely incorrect and she consistently shifted her center of gravity over her toes. When I had her do this exercise, we consistently worked on maintaining her center of gravity behind her toes and extending up through her heels, hamstrings and glutes. She improved greatly during our sessions.

11 Lateral Flexion/Rotation on the step barrel Spine Twist supine Side Lift I really loved using the step barrel for Jane, this was a much simpler apparatus for her to get in and out of to accomplish lateral flexion/rotation exercises. For the spine twist, she had to really concentrate on abdominal control as well as keeping her inner thighs together; all integral to hip muscle strength. For the side lift, again the step barrel proved to be much easier on Jane s knee joints and really made her aware of engaging her obliques and assisted with initiating the movement with her obliques first. Back Extension on the step barrel Swan Prep With this particular exercise, I had to watch Jane and make sure she kept the head in line with the spine and engaged her back extensor muscles.

12 Conclusion Though Jane really needed to concentrate on her overall hip muscle strength and flexibility, it was absolutely crucial for her to strengthen the muscles surrounding the hips as well. This concept provides overall balance to the body and, in Jane s case, by having weak core and hip muscles and a set-up for an altered gait, it eventually caused a worsening of her gait and new, increasing knee pain. Therefore, Jane was an ideal candidate for Pilates. She really required an overall body rebalance to help with knee and hip issues while taking into account her history of prolapsed uterus which had led to a complete lack of core strength associated with core exercise aversion. Even though Jane and I did not progressing as quickly as I had hoped in the beginning, she definitely became stronger overall and will soon be able to move into some intermediate exercises. Pilates has done wonderful things for her and she has become a strong advocate for the system.

13 Works Cited Figure 1. Darling, David. Ball and Socket Joint. Retrieved from Figure 2. Dr. Kupe Medical Lecture Notes. (2011, March 14). Hip Fracture. Retrieved from Isacowitz, Rael. (2014). Pilates Second Edition. Champaign, IL: Human Kinetics. Taylor, Tim. Muscles of the Hip. Retrieved from

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