Pilates for the Post Periacetabular Osteotomy (PAO) Client Stacey Barnes September 28, 2014 Oceanside, CA 1
Abstract This paper examines how Pilates is used as a conditioning program for a client post Periacetabular Osteotomy, commonly referred to as PAO, as well as hip arthroscopy, for acetabular dysplasia. PAO is a complex surgical treatment for acetabular dysphasia that preserves and enhances one s own hip joint rather than replacing it with a prosthetic implant, such as a total or part hip replacement. This paper provides an overview of hip function, acetabular dysplasia, a case study of myself as someone who has undergone bilateral PAOs, and the effectiveness Pilates has had on overall stability, mobility, flexibility, and strength of the hips. 2
Table of Contents Page 1: Title Page Page 2: Abstract Page 3: Table of Contents Page 4-8: Anatomical Description/Diagram of Hip Page 9: Introduction Page 9-10: Case Study Page 10-11: Conditioning Program Page 11-14: Rational for Conditioning Program Page 14-15: Results for Conditioning Program Page 15-16: Conclusion Page 17: Bibliography 3
Anatomical Description and Diagram of the Hip 4
The pelvic girdle consists of the sacrum, the coccyx, and the two hip bones. For the purpose of this paper, the focus will be on the hip bones. Each hip bone is formed by the fusion of three smaller bones: the ilium at the rear, ischium at the lower front, and the pubis above it. Usually by the age of 25, these three smaller bones fuse together in a Y- shaped cartilage in the acetabulum. Each hip bone is connected to the corresponding femur through the hip joint (femoral head and acetabulum), which is commonly referred to as the ball and socket joint. In healthy hips, the femur has a ball- shaped knob on the end that fits directly into the acetabulum. Articular cartilage surrounding the femoral head and acetabulum is kept smooth and slippery by synovial fluid, which allows the bones to move easily without pain. The articular cartilage acts as a weight- bearing protection for the hip joint. An additional, specialized piece of cartilage called the labrum surrounds the outer part of the acetabulum making the socket deeper to provide more stability for the hip joint. The ligaments, tendons, and muscles around the hip joint hold the bones (ball and socket) in place. The hip joint is the second largest weight- bearing joint in the body. Thus, healthy hips support a person s weight and allows one to move without pain. The muscles acting on the hip joint provides movement, strength, and stability to the hip joint. These muscles allow for various ranges of motion in flexion, extension, adduction, abduction, internal rotation, and external rotation. A healthy hip joint is very sturdy and stable because of the fit between the femoral head and acetabulum as well as strong ligaments and muscles at the joint. Numerous hip muscles work together to create different types of movement, but there are major muscles responsible for each movement. For example, the psoas major and iliacus are the main hip flexors; the gluteus maximus is the primary hip extensor; and the gluteus medius and gluteus minimus are the chief contributors to hip abduction. Although the hip muscles noted above have individual actions, some hip muscles have greater ability to sustain one s posture. These hip or pelvic region muscles work together with the neck, shoulder girdle, core, lower leg, and supporting muscles of the spine to provide the ability to stand and maintain good posture. The following table demonstrates the 5
complexity of hip muscle functions: Muscles: Flexion Extension Abduction Adduction Internal Rotation Iliopsoas (psoas/iliacus) Rectus femoris External Rotation Sartorius Tensor fascia latae Pectineus assists Adductor longus assists Adductor brevis assists Gracilis Biceps femoris long head Semimembranosus assists assists, long head Semitendinosus assists Gluteus maximus Adductor mangus Gluteus medius anterior fibers all fibers posterior fibers posterior fibers all fibers all fibers lower fibers anterior fibers all fibers posterior fibers 6
Glutes minimus Piriformis Obturator internus Obturator externus Quadratus femoris Gemellus superior Gemellus inferior hip in flexion 7
The problem is: when addressing acetabular dysplasia (shallow hip sockets) of the hip joint, we examine the head (ball) of the femur (thigh bone) and the amount of coverage in the acetabulum (hip socket). In a normal hip, the femoral head is covered adequately and well positioned in the acetabulum. In a dysplastic hip, the acetabulum is shallow and the femoral head is partially covered (see below diagram). Normal Hips Mild Dysplasia Severe Dysplasia Once symptomatic acetabular dysplasia is clinically assessed and diagnosed, an appropriate treatment for individuals under the age of 40 (who meet the criteria of minimal arthritis, good range of motion, and mild symptoms) undergo a complex surgical procedure called Peri- acetabular Osteotomy (PAO). This procedure is designed to preserve and enhance one s own hip joint rather than undergoing a partial or total hip replacement. It is designed to relieve pain and instability of the hip caused by an abnormally shallow acetabulum. In this procedure, three precise cuts across the pelvis (i.e., at the illium, pubis, and ischium) are made to detach the acetabulum from the pelvis. Once the acetabulum is carefully detached from the pelvis, it is rotated so that it is properly aligns with the femoral head to stabilize the hip and provide adequate support for the femoral head, then surgical screws are anchored to hold the acetabulum in place. The incision is closed and bandaged. Crunches are used for the first 2-3 months. Most patients can walk unaided in 3-4 months. Full recovery and healing takes 6-12 months. 8
Introduction An increased interest in acetabular dysplasia in young adults is on the rise as surgical treatments advance and as knowledge and understanding of the condition grows. Left unattended, dysplasia gets worse over time causing horrible pain and instability in the hip joint. Symptoms can occur several years before the onset of osteoarthritis and bone spurs. It is very important that an accurate diagnosis is made early on so that treatment options are not missed. If an individual undergoes a Periacetabular Osteotomy for dysplasia, once the healing and recovery process is completed, it is important for the individual to begin an exercise program to continue strengthening and stabilizing the muscles around the hip joint and to work the body as a whole. Pilates can create a deep awareness and understanding of the body, which is extremely beneficial to a person with muscles imbalances and compensatory movement patterns. Case Study The client for this study is myself, a 39 year old female with a history of bilateral hip dysplasia. Rehabilitation treatments have included bilateral PAOs (Periacetabular Osteotomies) and hip arthroscopy surgeries, physical therapy, Chiropractic and ART (Active Release Technique) care, and a year and a half of private Pilates sessions at a physical therapy clinic. Although the bilateral PAOs have allowed for better aligned of the hip joints, post- surgery adhesions, grade one arthritis, and muscles imbalances around the hip joint remains; the latter due to hypermobility and compensation patterns. Prior to the start of the program, Chiropractic and ART was used on a weekly basis to realign the pelvis and to release tight muscles due to imbalances and movement compensation patterns. Once the muscles around the hip joints become fatigued or the hips themselves become unstable or misaligned, the gate is compromised, I find myself limping, and inflammation is present within the hip joints. 9
My main goals for the following conditioning program is to increase overall pelvic stability, with a focus on increasing hip flexor and extensor flexibility and strength, increasing gluteal and external rotator stability and strength, and gluteal neuromuscular re- education to address muscle activation. Finally, to create additional mobility in the right hip joint. Conditioning Program Block Sessions 1-10 Sessions 11-20 Sessions 21-30 Warm Up Pelvic Curl Spine Twist Supine Chest Lift Chest Lift with Rotation Roll Up w/ Roll Up Bar Mini Roll- Ups Mini Roll- Ups with Obliques Roll- Up Top Loaded Roll Up Spine Twist Supine Double Leg Stretch Single Leg Stretch Criss Cross Foot Work Parallel Heels Parallel Toes V Position Toes Open V Heels Open V Toes Calf Raises Prances Single Leg Heel Single Leg Toe Cadillac: Parallel Heels Parallel Toes V Position Toes Open V Heels Open V Toes Calf Raises Prances Single Leg Heel Single Leg Toe Hip Opener Chair: Parallel Heels Parallel Toes V Position Toes Open V Heels Open V Toes Calf Raises Prances Single Leg Heel Single Leg Toe Abdominal Work Hundred Prep Hundred or coordination Cadillac: Breathing with Push Through Bar Teaser 1 Double Leg Double Leg with Rotation Hip Work Frog Circles (Down, Up) Openings Cadillac: Supine Single Leg Series Frog Circles (Down, Up) Hip Extension Bicycles Extended Frog Extended Frog Reverse Circles (Down, Up) Openings 10
Spinal Articulation Bottom Lift Botton Lift Bottom Lift with Extension Short Spine Long Spine Stretches Side Split Standing Lunge Kneeling Lunge Full Body Integration (F/I) Elephant Scooter Upstretch 1 Reverse Knee Stretch Up Stretch 2 Long Stretch Arm Work Arms Supine Series or Arms Sitting Series Chair: Shrugs Tricep Press Sit Arms Kneeling Series Full Body Integration (A/M) Long Back Stretch Leg Work Single Leg Skating Chair: Backward Step Down Chair: Frog Back Lateral Flexion/Rotation Chair: Side Stretch Mermaid Chair: Side Kneeling Stretch Back Extension Chair: Swan Basic Pulling Straps 1 Pulling Straps 2 Chair: Swan Basic Back Extension Single Arm Rational for Conditioning Program Given the fact I ve had a year and a half of private Pilates sessions with a BASI teacher at a physical therapy clinic, I made adjustments to the BASI Block System and incorporated spinal articulation and full body integration into the first ten sessions. If I were to design this program for a new client having no knowledge of Pilates or a client with basic knowledge of Pilates, I 11
would omit the spinal articulation and full integration blocks for the first ten sessions to allow the client the opportunity to focus on the foundational blocks. It should be noted that prior to beginning this conditioning program, one must be medically cleared by a physician, and a physical therapy program completed for post PAO patients. Throughout the conditioning program, an emphasis was placed on foot work, abdominal work, hip work, and leg work to restore proper movement patterns in the hip joint and to strengthen the muscles of the hips and gluteals to provide greater support for the hip joints. In sessions 1-10, I choose to start with the fundamental warm up to focus on the foundational exercises. Regardless of how long one has studied Pilates, I firmly believe in the importance of honing the fundamentals, which is great for pelvic stabilization and overall body awareness. Since my hip flexors are tight, weak, and I have a tendency to grip with the hip flexor muscles instead of recruiting correct muscles, I selected foot work on the reformer to focus on lengthening the hip flexor muscles while maintaining deep pelvic stability. For abdominal work, I began with Hundred Prep followed by either Hundreds or Coordination. Even though I have hypermobility in the joints, the hip flexor muscles are tight, weak, with extensive scar tissue and adhesions around the hip joints after bilateral PAOs (surgery was performed on the anterior portion of the hip; 14 scars on both hip bones). The Hundred Prep allowed me to work the abdominals, keeping my legs in a tabletop position and easing the strain on the hip flexor muscles. Depending on how the hip flexor muscles were responding on a given day, I would then preform either the Hundred or Coordination exercise. Although the muscles focus is abdominals for these exercises, I choose them for the added benefit of of hip flexor work when the legs are extended. Following the abdominal exercises I transitioned to hip work to focus on pelvic stabilization and hip disassociation, allowing for hip joint to move freely in the hip joint and using adductor strength and control. Individuals with hip dysplasia tend to have a weak gluteus medius, gluteus minimums, and external rotators- - all of which makes abduction difficult. Since the gluteal medius is an essential muscle for gait and hip stability, I choose single leg skating for the leg block. The focus was on maintaining weight 12
on the supporting leg while fully straightening the moving leg completely. I choose the Side Split for the stretch to work the adductors. Since Single Leg Skating is an intermediate exercise, for a beginner client, I recommend Gluteal Side Lying Series or Gluteal Kneeling Series. For one of the full body exercises, I selected Scooter with a heavier weight setting in order to target the gluteals. In sessions 11-20, I switched to the Cadillac for the warm up series because of the required abdominal control and pelvic stabilization. Due to limitations in my right hip joint the roll up must be executed correctly, maintaining a proper C curve at all times to prevent the femur head from jamming into the acetabular, allowing for adequate space within the hip joints. Constant focus on aligning the shoulders above the hips while lengthening from the spine in the C curve was a nice challenge to my hip joint. Although foot work on the Cadillac is a contraindication for someone with a hip replacement, someone with a PAO like myself, can benefit from the series when executed correctly. The muscle focus for this series is hamstrings; however, proper pelvic stabilization, deep core muscles, and actively using the legs and feet, all while controlling the range of motion and keeping the sacrum anchored, foot aligned, and proper knee tracking allowed for mobility in the joint space and hip extensor stretch and strength. For someone with less Pilates experience, I recommend limiting the range of motion or possibly forgoing this series all together and return to foot work on the reformer. Hip Opener was also included to target the hip external rotator muscles as the muscles focus, but also for the adductor and hip extensor control and stretch. Teaser 1 in the abdominal block was specifically chosen for hip flexor control and strength, though in the beginning a large exercise ball was used as a modification to support the hip flexors. For the hip work series, Supine Single Leg Series was selected to allow for the independent movement of the hips. Stabilizing from the core and visualizing lengthening the femur out of the hip joint provided the hip joint with the freedom to move. Although the muscles focus is hamstrings, the objectives of hip extensor control, hip adductor control, and hip disassociation were maximized. In these sessions, I added in Standing Lunge for a hip flexor stretch and Reverse Knee Stretch for hip 13
flexor strengthening. Lying Side Single Leg is a phenomenal hip work series that maximizes range of motion in the hip joint and is a great alternative to Supine Single Leg Series. In the leg work block, Backward Step Down enabled a focus in gluteal and hip extensor control. In sessions 21-30, I progressed to foot work on the chair for another dynamic of hip extensor control and hip flexor strength (i.e., single leg portion of the series). I transitioned to the reformer for Abdominals Legs in Straps series for a greater challenge of hip flexor strength. I continued on the reformer for hip work to focus on hip disassociation. I choose Kneeling Lunge for a nice hip flexor stretch. For leg work block I switched back to the chair for Frog Front to once again focus on hip external rotators strength. Results for Conditioning Program The aforementioned Pilates conditioning program was conducted 2-3 times a week. At the beginning of the program, my hip flexor and extensor strength was incredibly weak, and I suffered from significant gluteal weakness and poor neuromuscular activation. This caused all abduction exercises to be extremely difficult. Hundred Prep was even difficult to execute. During Arms Supine Series, I found myself resting in between exercises. I found that it was tough for me to hold any position that required hip flexor strength or abduction. Another example was not being able to extend my leg completely during the Single Leg Skating exercise. Even during Foot Work on the reformer, specifically when performing Calf Raises, Prances, Single Leg Heel, and Single Leg Toes, my gluteal medius wasn t firing correctly. My struggle with activating gluteus muscles resulted in my hip internally rotating. As the sessions progressed, noticeable gains in the strength and stability of my hip flexors, gluteal muscles, and external rotator muscles were observed. I was able to maintain the 14
position of the exercises longer and increase repetitions. However, some of the exercises in the Leg Block are still challenging, such as Forward Lunge and Hip Opener on the chair. Future sessions will include a focus on the Leg Work Block and Teasers. It should be noted that Teasers remain very challenging for the hip flexors. I believe a main reason for this is due to significant scar tissue and adhesions around the hip muscles and tensor fascia latae (TFL) from the Periacetabular Osteotomy surgeries. Initially, I conducted chiropractic and Active Release Technique therapy sessions on a weekly basis transitioning to two sessions a month. As the muscles adhesions and scar tissue continue to be broken up, I believe greater increases in the hip flexors will be achieved. Conclusion An individual who underwent either unilateral or bilateral Periacetabular Osteotomy can benefit from Pilates, albeit the timing of this exercise program needs to be appropriate as well. Medical clearance from a physician and completion of physical therapy program is needed. Manual therapy to break up muscles adhesions and scar tissue is highly recommended (Active Release Technique is strongly encouraged). Foam rolling can be beneficial to help break up scar tissue and adhesions, but not in the same way as manual therapy. As I discovered, a commitment to Pilates 2-3 times a week produced improvement in flexibility and strength in my hip flexors and extensors, an increase in stability and strength in my gluteal and external rotator muscles, and improved neuromuscular connection to my gluteal muscles resulting in more consistent activation of these muscles. Finally, overall stability and mobility in the hip 15
joints have improved. In closing, Pilates is recommended as a vital part of the recovery process for PAO surgery patients to regain flexibility, stability, and strength. 16
Bibliography 1. Biel, Andrew. Trail Guide to the Body- 4 th Edition. Boulder, Colorado: Books of Discovery, 2010. 2. Calais- Germain, Blandine. Anatomy of Movement- Revised Edition. Seattle, Washington: Eastland Press, 2007. 3. S. Sturridge and M. Bankes. Focus on Acetabular Dysplasia in Adults. http://www.boneandjoint.org.uk/content/acetabular- dysplasia- adults 4. (Hip Anatomy Imagery) http://www.nvasi.com/hip- bone- anatomy/ 5. Hospital for Special Surgery website. http://www.hss.edu/conditions_hip- dysplasia- adolescents- young- adults.asp 6. International Hip Dysplasia Institute website. http://hipdysplasia.org/adult- hip- dysplasia 17