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1 Return the Feet to Life Through Pilates: Employing the BASI Pilates Repertoire in the case of Plantar Fasciopathy Katherine Bélanger May 2015 Rosemère, Québec, Canada Comprehensive Course

2 Abstract Plantar Fasciopathy is a painful condition affecting the plantar fascia of the foot. There are many factors that contribute to a person developing this condition, many of which can be reduced to poor alignment of the joints and faulty biomechanics. It is here that Pilates can be employed to realign the body and re-educate the person to move with awareness. We will be introduced to a person with a specific case of plantar fasciopathy who will serve as an example for how the BASI repertoire can be employed to bring relief from this painful condition. The Block System Program constructed for this specific client consists of Fundamental exercises, and had positive effects on the client s health.

3 TABLE OF CONTENTS Page 1 - Abstract Page 4- Diagrams and Anatomical Description of Plantar Fascia Page 5- Introduction Page 6 - Case Study Pages 7-10 BASI Block System Page 11- Conclusion Page 12- Bibliography

4 Diagrams and description of the Plantar Fascia Medial view of the plantar fascia, including it s fascial continuity with the Achilles tendon via The plantar fascia is a wide band of connective tissue on the bottom of the foot. Originating at the proximal phalanges (the base of the toes), it extends into the front of the calcaneus (the heel bone) by blending into the periostieum of the calcaneus. It also picks up another piece from the 5th metatarsal on the lateral side of the foot. The band of tissue is called an aponeurosis, which is like a wide, flat tendon. There is a similar aponeurosis in the palm of the hand. Stretch tension from the plantar fascia prevents the spreading of the calcaneus and the metatarsals and maintains the medial longitudinal arch During gait, many forces stress the foot and could disrupt the medial longitudinal arch. Without a mechanism to maintain this arch, we could not walk in a systematic and efficient manner. The orientation of the plantar fascia helps maintain the arch throughout gait and contributes significantly to the appropriate amount and timing of pronation and supination during the gait cycle. (Bolgla, 2004) Inferior (plantar) view of the plantar fascia, including the wide band of tissue connecting the calcaneus to the base of the toes. via Plantar_fascia.gif

5 Introduction Plantar fasciopathy is a term used to describe damage to the plantar fascia resulting in heel pain. The term covers the two phases of damage, the inflammatory phase referred to as plantar fasciitis, and the non-inflammatory degeneration phase referred to as plantar fasciosis. Researchers have not reached a consensus on whether patients presenting with heel pain that had formerly been diagnosed as plantar fasciitis are actually experiencing an inflammatory condition, or whether it is a degenerative condition (fasciosis). Whether inflammation is present or not will determine the course of the conditioning program the Pilates practitioner will design for their client. When inflammation is present (swelling, heat and acute pain) we will limit the client s range of motion, perhaps even avoiding exercises that involve the foot and ankle in weight bearing positions. When there is no longer swelling and heat in the affected area we can progress to restoring/expanding range of motion in the joints of the ankle and foot, as well as stretching muscles of the lower extremity and correcting muscle imbalance and faulty alignment. In fact, clinical treatment of PF will often involve stretching and strengthening exercises as well as neuromuscular reeducation efforts. Being as causes of PF have been found to include excessive or prolonged pronation of the foot, high rigid arches, unsupportive or poorly constructed footwear, overuse, and poor gait mechanics, addressing these core causes in conservative, progressive manner can be highly beneficial. Being as the Pilates instructor does not necessarily have any formal training in the diagnosis of pathology, or in-depth training in gait mechanics, it falls to a medical professional to make the diagnosis and inform the Pilates teacher. Once informed, the Pilates instructor may use what tools they are qualified to employ to

6 determine if the client displays insufficient flexibility of the joints of the foot and ankle, or poor alignment during exercises in the Pilates session. As will be shown in the Block System portion of this paper, BASI repertoire contains many of the movements prescribed as correctives for PF, and can therefore aid in a client s recovery from this condition and return to health.

7 Case Study The particular client for whom this program was designed is a 30 year old man who began to experience plantar fasciopathy in the summer of His plantar fasciitis presented with sharp pain, swelling and heat and was diagnosed by a Physical Therapist, who prescribed icing, antiinflammatory drugs, orthotics and a course of gentle stretching. The PT also advised him to avoid exercises such as weighted squats where the plantar fascia could become compressed. The client is very active, especially in summer when he rides his bicycle as his main form of transportation, as well as going to the gym to perform a general conditioning routine. He has been active for many years, snowboarding, doing yoga and going to the gym regularly on top of riding his bike and walking. He works as an ESL teacher and waiter. At the time of the onset of pain, he was standing and walking for long periods of time in dress shoes for work. Currently he works 6-8 hour shifts on his feet in a restaurant, walking and standing as well as carrying loads up and down several flights of stairs. He is 6 4 tall, 190lbs, asthmatic and has highly inflexible hips and thighs meaning that he has a smaller than normal than normal range of motion in external rotation, extension and flexion of the hip with knees both flexed and extended. This restricts his ability to perform many movements. His PF no longer involves signs of inflammation, but he does experience unilateral pain (left foot) upon waking and taking his first steps out of bed. He is enthusiastic about undertaking a Pilates program, and hopes to gain flexibility and control, as well as help in resolving his PF pain. He is a new client, and at the time of the design of this program had done fewer than 10 Pilates sessions.

8 BASI Block System Program Standing Roll-down Used as a tool of assessment to observe the client s body symmetry and restrictions in the movement of his spine. Using the Roll-down to start the session, we begin to develop the mindbody connection for the rest of the session. The client performs a modified Standing Roll-down with his knees slightly bent, to facilitate smooth movement of the pelvis over the greater trocantors. Warm-up Pelvic Curl (Assist: Block or ball between knees to facilitate adductor engagement. Otherwise the client splayed his knees. Block was removed after the first few sessions.) Spine Twist Supine Chest Lift Chest Lift with Rotation Focus of the warm-up is teaching Pilates principles to this new client, as well as engaging the body in movements with straightforward choreography which challenge muscular endurance while assessing for muscular imbalance and compensation patterns. Footwork The footwork block is integral to addressing the plantar fasciopathy issue, as well as providing the benefits of warming up the body and strengthening hip and knee extensors. Each exercise in this block provides important information about the client s habitual foot-ankle-knee-hip

9 alignment, as well as providing an excellent opportunity for movement reeducation. It is the opinion of this student that the entire repertoire of Footwork exercises on all apparatus would be beneficial. However, being as the client is a beginner and is presenting with foot-ankle problems, we will restrict the footwork to the Reformer for the first sessions. This avoids overwhelming the client with the flexibility challenge of the Cadillac Footwork, or the added stability required for the Chair Footwork. The Reformer repertoire also includes the Prehensile position, which is a great stretch for the intrinsic muscles of the foot, a corrective stretch for those with PF. Keeping in mind time restraints and balance of the session, the entire Reformer footwork will be executed by the client as often as possible in his sessions. Parallel heels: PF often involves a decreased range of dorsiflexion so encouraging proper dorsiflexion at the ankle (instead of extension of the toes) is imperative. Parallel toes: Excellent stability challenge for the ankle, targeting the muscles of the rollthrough phase of the gait pattern. Supinations and pronations should be brought to the client s attention so that correct alignment can be practiced. V-position toes: Owing to the client s limited range of external rotation, care is given to creating the V shape from the hip and not the knee or by everting the foot. Wide V position heels and toes: All of the same considerations as above, as well as the increased challenge from the larger ROM at the hip. Calf raises: This exercise in particular (along with Prances) mimics the ROM and objectives of corrective physical therapy exercises for the plantar fascia. The contract-stretch-contract motion creates larger ranges of functional flexibility in the tissues of the foot and lower leg. Encouraging the client to smoothly track the foot and ankle through proper alignment on both the concentric and eccentric phases of movement is important in helping them to reeducate patterns of over-

10 pronation or excess mid-tarsal movement which both contribute to the development and perpetuation of PF. Being as the client has no pain in dorsiflexion or inflammation of the plantar fascia, we are gently and progressively working to create a greater range of dorsiflexion. Prances: Same considerations as calf raises, while also watching for compensation patterns between the two sides of the body. Prehensile: As mentioned above the Prehensile position is an excellent and unusual stretch for the muscles of the foot, while also engaging the toe flexors to keep the toes firmly wrapped around the bar. Strong toe flexors are an important part of the biomechanics of a healthy gait cycle, helping to propel the weight of the body forward off the metatarsals, onto the toes and onto the other foot. Single leg heels and Single leg toes: Powerful movements for observing and correcting unilateral compensation patterns. Especially useful in addressing a unilateral condition such as the client s PF. Abdominal Work Reformer: Hundred Prep and Hundred I have chosen the Hundred Prep and Hundred for the abdominal strength and stamina focus, as well as the pelvic-lumbar stability required. Pelvic-lumbar stability is an essential component in healthy gait, and Hundred is a great place to train it. Additionally, the controlled and purposeful breathing of Hundred can be extraordinarily helpful for those with asthma as it gives an opportunity to strengthen the whole breathing apparatus. The Short Box series would also be a good set of exercises to train Pelvic-lumbar stability as well as strength of the trunk flexors. As the client is just starting out and in the experience of this student, beginners tend to work

11 through the exercises more slowly exercises from the short box series could perhaps be integrated with time in order to create more challenge for the client, as he becomes more familiar with the other exercises and we can be sure to finish all the blocks in time. Hip Work Reformer: Frog, Up and Down Circles, Openings Being as the client is a beginner, we will start by teaching the movement patterns on the Reformer. Once the movement pattern is clear and well-executed, it would be beneficial to progress to the Cadillac for the full Basic Springs Series (Frog, Circles, Walking, Bicycle). The work on the Cadillac has the advantage of loading the legs separately which gives an opportunity to work on imbalances that may exist between the two legs, or within the muscle groups of each leg. Hip Work is an excellent block to work on this client s hip inflexibility, encouraging progressive increase in range of motion with corresponding development of pelvic-lumbar stability. Spinal Articulation Spinal Articulation will be omitted from this client s program until they have completed 10 sessions. At that point, Bottom Lift would be a good place to start working on moving the spine bone by bone, without the added difficulty presented by the hip flexion and knee extension in the Monkey Original.

12 Stretches Reformer: Standing Lunge The Standing Lunge is a great exercise to challenge the client s flexibility and help to bring greater range of motion to the hips. Keeping in mind the client s heel pain, the exercise should be modified to omit the dorsiflexion during the hamstring stretch phase of the exercise. Placing a great deal of weight down directly into the site of pain would be detrimental to the client s recovery. Full Body Integration Fundamental/Intermediate This block would be omitted being as the client has had fewer than 10 sessions. Arm Work Reformer: Arms Supine Series The Arm Work series chosen is appropriate to the level of the client in their Pilates practice. It also provides additional Pelvic-lumbar and trunk stabilization challenge, to work the abdominals. However, being as the client is quite a large person, and that he lifts weights regularly, the exercises in this series do not provide enough overload to create strength gains. In order to provide the client with appropriate challenge for his arms, it would be good to progress him towards more challenging exercises (arms sitting series, kneeling series or standing series) as soon as he is proficient in the supine series. On the other hand, the stability required to keep the legs in tabletop and correct alignment of the shoulder girdle is challenging and the client should not be progressed simply because he doesn t experience a significant challenge in his arms.

13 Learning to recruit appropriate stabilization will help him in his conditioning at the gym and also in his job, where he is lifting heavier loads. Full Body Integration Advanced/Master This block will be omitted as it is not appropriate to the level of the client. Leg Work Side Lying Gluteals Series Proximal muscle weakness from the gluteus medius, gluteus minimus, tensor fascia latae, or quadriceps muscles can contribute to plantar fascia abnormalities. Weakness in these muscles inhibits their ability to assist with the lower extremity load response, which results in greater transmission of shock to the supporting foot structures. (Plantar Fasciitis and the Windlass Mechanism, Bolgla and Malone, 2004) As we can see from the above research, additional work for the gluteals can be very beneficial for PF recovery, which is why I have chosen this series over other leg work focusing on the adductors or hamstrings. This series was taught to the client in the first session, and it proved very challenging. It is not clear whether the weakness in his gluteals is contributing to his PF, but strengthening the gluteus medius will likely contribute to healthy gait and correct joint mechanics in cycling and other activities.

14 Lateral Flexion/Rotation Chair: Side Bend Side bend is a great exercise to build strength and awareness in the obliques without placing strain on the client s tight hips. (To do Mermaid on the Reformer, he requires a lot of assists to get into the correct position on the carriage.) Back Extension Chair: Swan Basic Being as the client has tight muscles all along the posterior chain, thoracic extension is a challenging range of motion. Doing the extension on the chair with medium-heavy resistance (an assist to the original exercise) provides excellent tactile feedback to help lift up the thoracic vertebra. Progressively lowering the resistance before moving to a more challenging back extension pattern would help the client build the appropriate strength and body awareness.

15 Conclusion Using the Block System to create our sessions, we can address global and local factors that may contribute to the client s PF, including pelvic-lumbar instability, gluteal weakness and ankle alignment. The BASI repertoire provides a wide variety of exercises appropriate to the client s level, as well as exercises to progress towards. The Block System gives a framework that allows us to address the client s painful issue while continuing to work the entire body in a flowing session. It is possible to apply scientific research findings to our Pilates teaching without overstepping the boundaries of our scope of practice. What s more, by marrying the research to these deeply intelligent exercises, we can get profound results After performing several sessions using this program, the client reported decreased pain, increased mobility and a sense of having been challenged in a different way than at the gym. It is my hope that he will continue his Pilates practice, and that a carefully selected program of exercises will continue to help him find relief from plantar fasciopathy, so he may perform his many and varied daily tasks with spontaneous zest and pleasure. (Return to Life Through Contrology, Joseph Pilates 1960)

16 Bibliography Baravarian, B. (2012). Refining The Treatment Algorithm For Plantar Fasciitis And Plantar Fasciosis. Podiatry Today, 23(5). Retrieved from Barrett, S.L. (2006). Should you change your approach to plantar fasciosis?. Podiatry Today 19(11). Retrieved from Bolgla, Lori A.; Terry R. Malone. (2004) Plantar Fasciitis and the Windlass Mechanism. Journal of Athletic Training, 39(1): Retrieved from PMC385265/ Fullem, B. How core muscles affect the lower extremity. Podiatry Today 21(4). Retrieved from Isacowitz, R. (2006) Pilates. Champaign, IL: Human Kinetics. Isacowitz, R. (2013) BASI Pilates Study Guide Comprehensive Course. Costa Mesa: Body Arts and Sciences International. Miller, W.J.; Pilates J.H. (1998) A Pilates Primer: The Millenium Edition. Presentation Dynamics. Myers, T.W. (2008) Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, 2e. New York, New York: Churchill Livingston THE REAL TRUTH ABOUT PLANTAR FASCIITIS. (2013, July 2). Retreived May 21, 2015 from