Reducing Knee Pain and Instability Through Pilates

Transcription

1 Reducing Knee Pain and Instability Through Pilates Catherine Keene 25 November Comprehensive Apparatus Program La Playa Pilates, Santa Barbara, California

2 Abstract Dillon is a twenty seven-year-old male suffering from pain and instability in his right knee caused by a series of dislocations over the past fifteen years. I created a program with the goal of increasing stability and decreasing pain. In order to achieve these goals the program focused on strengthening the gluteus medius and quadriceps, using exercises from the BASI comprehensive repertoire as well as Samantha Wood s Pilates for Injuries and Pathologies. The principles of training, rather than exercise, were also applied to the program because of the client s history as a weightlifter. Over time the client did notice a decrease in pain, and an increase in his feelings of security in his knee. 2

3 Table of Contents Abstract...2 Anatomy of the Knee...3 Case Study...4 Training vs. Exercise...5 BASI Program...6 BASI Program Discussion...8 Conclusion...9 Bibliography

4 Anatomy of the Knee The knee is made up of two joints, between three bones: the Tibiofemoral joint, in which the tibia is connected to the femur by the tibial collateral ligament and the meniscopatellar ligament, and the Patellofemoral joint, in which the patella is connected to the femur by the quadriceps tendon. Segments of the quadriceps tendon that connect the patella to the tibia are called the patellar retinacula. The patella rests in a groove on the femur called the trochlea. The trochlea, distal head of the femur, and the back of the patella are all covered by articular cartilage, which, along with the synovial fluid, helps the patella move smoothly in the throchlear groove, and allows the knee to function properly. 4

5 Case Study Dillon is a 27-year-old male with a history of injuries to his right knee. He first suffered a patellar dislocation at 12 years old, when he tripped over a fellow player during soccer practice. It remained dislocated for about ten minutes before the paramedics arrived and put it back in place. Since that time he has dislocated it an average of once a year, some only subluxations, but there have been three more severe, full dislocations in the years since the first one. After the first and the three subsequent full dislocations he did have some physical therapy. Several years after the first dislocation, he noticed a free-floating object in his knee that could be felt through the skin, and would occasionally cause a sticking sensation that would limit the range of motion. In these cases he could manually move the object out of the way and full range of motion would return. He did not feel any pain during these episodes, only slight discomfort, and he treated it more as a party trick. During high school he participated in weight training. During a training session, he was squatting 360 pounds when the object shifted into the tibiofemoral joint, and caused his knee to lock before he achieved full extension. The spotter intervened, preventing any serious harm, and Dillon was able to digitally manipulate his knee and regain full range of motion. Several months later, at the age of eighteen, he had arthroscopic surgery to remove the object, which was a piece of bone that had broken off and calcified over time. During this surgery they also performed a lateral release, and shaved down the posterior side of the patella. The lateral patellar retinaculum, one of the ligaments that connects the quadriceps to the patella, can tighten over time (often due to 5

6 injury), and begin to pull on the patella, causing it to track improperly. In a lateral release surgery, some of the connective tissue in the patellar retinaculum is severed, with the idea that this will relieve the tightness and allow the patella to track properly. Dillon had physical therapy after the surgery, and has done yoga, rock climbing, and some Pilates in subsequent years. He avoids any sport or exercise that includes lateral movements. He says the only thing the surgery accomplished was to make him more aware of the instability in his knee, and more careful. In 2016 Dillon started power lifting, and had a drastic increase in everyday knee pain. He stopped in the beginning of 2018, but would like to start again soon. He is exploring Pilates as a way to strengthen and protect the joint before he returns to a more loaded training program. After researching his knee condition I have learned that weighted squatting is most probably the worst thing he could choose for his knee, and have strongly encouraged him to avoid it. He is under the assumption that he will need a knee replacement by the time he is in his early 40s. Training versus Exercise When Dillon was weight training, he followed the tenets set out by Mark Rippetoe in his book Starting Strength: Basic Barbell Training. Rippetoe was a competitive power lifter for ten years, and has been working as an Olympic lifting coach since In a discipline such as Olympic Weightlifting, an athlete is not just exercising. Instead, they are training: working methodically towards a specific goal. For Dillon, his goals were to dead lift and squat three times his body weight. The 6

7 idea of training is this: adequately stress the muscles, allow them to recover, and they will adapt. Progressive overload is the key to increasing strength. In this program, I will apply the tenets of training to a BASI Pilates program, focusing on strengthening the gluteus medius, which will help stabilize the knee, and the vastus medialus oblique (VMO), one of the quadriceps, which will medially stabilize the patella. Sets of exercises to achieve these goals will progressively increase in load or intensity over two lessons twice a week for four weeks, and will be included in a full-body program. My goal in creating this program for my client is to increase stability, thereby reducing his sense of anxiety around his knee, and decrease pain. I believe he also suffers from chondromalacia, the erosion of the cartilage on the underside of the patella, and therefore should not return to weighted squatting, as the load on the patellar groove is incredibly high and will, in the long run, only serve to further erode the cartilage, and lead to more pain. Therefore, another goal is to convince him to continue with Pilates and perhaps consider other, less damaging, forms of exercise when he feels ready to continue with higher-intensity training. 7

8 BASI Program Block Week 1 Week 2 Week 3 Week 4 Roll Down Pelvic Curl Spine Twist Roll Down Pelvic Curl Spine Twist Roll Down Pelvic Curl Double Leg Warm Up Supine Supine Stretch Chest Lift Chest Lift Chest Lift with Rotation Leg Changes Chest Lift with Rotation Leg Changes Stretch Criss Cross Foot Work Abdominal Work Parallel Heels Parallel Toes Narrow V Wide V Heels Wide V Toes Heels Toes 100 Prep Coordination Single Side Coordination Parallel Heels Parallel Toes Narrow V Wide V Heels Wide V Toes Heels Toes Short Box Series: Round Back Flat Back Tilt Twist Round About Parallel Heels Parallel Toes Narrow V Wide V Heels Wide V Toes Heels Toes Short Box Series: Round Back Flat Back Tilt Twist Round About Roll Down Pelvic Curl Double Leg Stretch Stretch Criss Cross Parallel Heels Parallel Toes Narrow V Wide V Heels Wide V Toes Heels Toes Abdominals Legs in Straps: Double Legs Double Legs with Rotation Hip Work Spinal Articulation Stretches FBI I/II Arm Work Reformer: Frog Circles Down Circles Up Openings Bottom Lift Standing Lunge Up Stretch I Elephant Up Stretch II Kneeling Arm Series: Cadillac: Frog Circles Down Circles Up Walking Bicycles Bottom Lift w/ Extension Standing Lunge Up Stretch I Elephant Up Stretch II Kneeling Arm Series: Hip Series: Frog Circles Down Circles Up Walking Bicycle Tower Standing Lunge Up Stretch II Long Stretch Kneeling Side Arm Series: Hip Series: Frog Circles Down Circles Up Walking Bicycle Bottom Lift w/ Extension Standing Lunge Up Stretch II Long Stretch Kneeling Side Arm Series: 8

9 Chest Expansion Biceps Circles Up Circles Down FBI III/IV N/A N/A Leg Work Lateral Flexion and Rotation Back Extension Lateral Step Down 3x5 Sitting Knee Flexion 3x5 Terminal Knee Extension 3x5 Side Over on Box Breaststroke Prep Chest Expansion Biceps Circles Up Circles Down Lateral Step Down 3x5 Sitting Knee Flexion 3x5 Terminal Knee Extension 3x5 Side Over on Box Breaststroke Prep Deltoid Reach Cross-Arm Pull Triceps Arms Overhead Kneeling Hip Extension Lateral Step Down 3x5 Sitting Knee Flexion 3x5 Terminal Knee Extension 3x5 Side Over on Box with Rotation Pulling Straps I Pulling Straps II Deltoid Reach Cross-Arm Pull Triceps Arms Overhead Kneeling Hip Extension Lateral Step Down 3x5 Sitting Knee Flexion 3x5 Terminal Knee Extension 3x5 Side Over on Box with Rotation Pulling Straps I Pulling Straps II BASI Program Discussion For the first week of the program, I tried to focus on establishing some awareness of the principles of Pilates, helping him find a neutral spine, and developing pelvic stability. He has developed a lot of body awareness through weight training, but demonstrated some impatience with the pace and weight load of Pilates. So my intention was to challenge him without giving him exercises that were too complex. For the Warm Up, I focused on developing pelvic stability, and relaxing the hip flexors in order to maintain a neutral pelvis. In Foot Work, we focused on the 9

10 eccentric contraction, in order to activate and work the hamstrings. Abdominal Work was particularly challenging for him, as it is somewhat neglected as an individual element in Olympic Weightlifting, and the principles are entirely contrary to Pilates. In Hip Work we again focused on maintaining pelvic stability, and keeping a small range of motion that allowed him to straighten his legs completely, as his hamstrings are not very mobile. For Spinal Articulation I had him focus on activating his gluteals and using his adductors to keep his knees parallel. For Stretches, both his hip extensors and hip flexors are quite tight, so we focused on both. For Full Body Integration, I decided to challenge him. The challenges here were both the mobility of his hamstrings, and his scapular stability. He has a tendency to adduct his scapulae (something he brings with him from weight training), and finding effective cueing to stop him doing this was a real challenge. Eventually we switched to leg-pull front in order to discuss what I wanted to achieve, and had more success there. For Arm Work, I gave him a series not necessarily suited to a beginner, but decided to challenge his full body stability because he is quite strong, and he did well. I skipped the second Full Body Integration for the first two sessions, and moved on to Leg Work, which is the focus of this program. This is where I applied the principles of training, having Dillon complete three sets of five repetitions, switching off between each leg. For the two exercises on the reformer, we started with one blue spring, and I will progressively add load for the next three weeks. For Lateral Flexion and Rotation, I challenged him with Side Over on the Box, which was 10

11 indeed challenging. For Back Extension, as he works at a desk, I wanted to focus on general strengthening of the back extensors and opening of the pectorals, so emphasized external rotation of the shoulders and the eccentric portion of the movement. Over the next sessions, I increased the difficulty of the Warm Up and the Abdominal Work, and moved him to the Cadillac for Hip Work, in order to activate his gluteals more effectively. He enjoyed the single leg hip work series on the Cadillac, and I found his stability increased quite a bit here. Because there was such a focus on hamstrings throughout the program, I continued to have him do Standing Lunge for his stretch, and found a small increase in his mobility, though there is certainly still more to be achieved. His scapular stability and awareness increased, and I was able to introduce Up Stretch III and Long Stretch into the program, as well as Kneeling Hip Extension. For the Leg Work, I moved the blue spring to the button for the second week of three sets of five repetitions, and for the third week I had him stand, rather than sitting on the foot bar, with one blue spring back on the hook. For the final week of the program I moved the blue spring back onto the button and had him stand for the sets. This was quite challenging for the stabilizing leg, and I think was very effective. For Lateral Flexion and Rotation, I had him do the same exercise over the four weeks, but added repetitions and in the final sessions added a rotation. For Back Extension, I had him do Pulling Straps I and II, focusing on the external rotation of the shoulders. 11

12 Conclusion Though I had planned to complete the program with two sessions a week for four weeks, it actually took closer to ten weeks, as Dillon traveled frequently for work and attendance was not as frequent as either of us would have liked. Despite this, I noticed an improvement in stability of the right knee, and he remarked on a reduction of pain in his knee, and a greater feeling of confidence in it overall. Though the entire program was quite heavily focused on the hamstrings, I believe that using the training method of sets of repetitions, and methodically increasing the load, did have an effect on the efficacy of the exercises that were selected and implemented. Dillon plans to continue with Pilates, and I believe he will return to weight training, but is planning to avoid weighted squatting and will focus instead on other exercises. I think these two very different methods can complement each other nicely. 12

13 Bibliography Isacowitz, Rael, and Karen Clippinger. Pilates Anatomy. Human Kinetics, Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, Rippetoe, Mark, and Stephani Elizabeth Bradford. Starting Strength: Basic Barbell Training. Aasgaard Company, Wood, Samantha. Pilates for Injuries and Pathologies. Body Arts and Science International, Our Knowledge of Orthopaedics. Your Best Health. Common Knee Injuries, orthoinfo.aaos.org/en/diseases--conditions/common-knee-injuries/. 18 October