Hip Pain Knowing how structural deviations that occur in the hip joint can effect your client s movement. Keira Hart- Mendoza March 11, 2014 BASI CTTC in Herndon VA 2013-2014
ABSTRACT: As a Pilates instructor my job is to ensure that I am instructing my clients and students to move in a healthy manner. I am not a physical therapist, however my goal is to have enough anatomical knowledge so that I am aware of the vast differences between individual s ranges of motions (ROM) at the hip joint. In my experience as a mover and dancer, there are certain movements I cannot do no matter how many times I have stretched to strengthened the hip joint. Having more awareness of structural and functional deviations between certain individual s hip structures is helpful to build a Pilates work out regime for a client s need. The need could be to increase flexibility or to build strength, or both. All the while, it is my goal to instruct the client to make sure the individual is working within his or her anatomical structural ROM.
TABLE OF CONTENTS: Anatomical Descriptions and Diagrams of the Variations of the Hip Structure.. 4 Description of the Case Study... 5 The Importance of the First Meeting With a New Client....6 Conditioning Program For a Client With Tight Hips.9 Conclusion. 13 Bibliography....14
ANATOMICAL DESCRIPTIONS AND DIAGRAMS OF VARIATIONS OF HIP STRUCTURE: It s all about the geometry! Every person has a unique body shape and structure. The images below demonstrate a few of the variations that can occur in the bone structure of the hip joint (Femoral Acetabular) and in the pelvic region. These structural variations can lead to a smaller ROM, hip flexion, and hip extension. Here are four examples of structural deviations in the hip socket. Someone with tight hips might have one or more of these factors affecting their ROM and ability to flex or extend at the hip. Variation of the Angle of the Femoral Head: In this diagram you can see how the angle of the head of the femur can be extremely different from person to person. The angle of the top of the femur will cause the leg to sit in a different place in the hip socket and possibly lead to friction and or inflammation at the hip causing hip pain. Variation of the Femoral Head Length: In this diagram you can also see that the length of the head of the femur can vary from person to person. Again, this will cause the whole entire leg to have a different relationship to the hip and pelvic region. Variation between Female and Male Pelvic Bone Structures: This is a clear example of the difference in design between the male and female pelvis. The female pelvis is wider, for child bearing, in comparison to the male pelvis. This can also affect the angle of the acetabular joint as well.
Variations in the depth or shallowness of the hip socket: causing the head of the femur to misalign in the hip socket. CASE STUDY: I have been a dancer, mover, fitness enthusiast, and athlete for almost my entire life. From an early age, I noticed a difference in my body compared to others. I have never been able to squat with my heels connected to the floor. I cannot lower my pelvis comfortably below my knees before my body needs to make compensations. Many instructors (in yoga, pilates, dance, sports, etc.) have told me time and time again that if I stretched more I would be able to get my heels down in a squatting position. As science develops we are learning more and more about the human body. With new x- ray technologies, we are seeing for the first and becoming aware, that everybody has a slightly different bone structure. Yes, we all have hips, but we can t all use our hips the same way no matter how strong or flexible our hips become, due to the structural deviations that occur at the joint. Instead of
having the same expectation for all bodies to move the same way, I think we should be more aware as Pilates instructors that no two people can move the same way. Due to a body s structure, we have to be more mindful of compensations and adjustments that may need to be created when working with clients with tight hips. In this case study we will build a Pilates fitness regime for a person with limited range of motion in their hip joint to allow the individual to move well without ending the work out regime in pain. For the purpose of this case study the client with tight hips shall be named Anna. Anna is a dancer who has never done Pilates before, but has a great awareness of her body and appears to be in good physical condition. THE IMPORTANCE OF THE FIRST MEETING WITH A NEW CLIENT Every time we meet with a new client the goal should be to observe the client in action first before any other exercises are encouraged. This way we can begin by seeing how the client naturally moves. In BASI, we encourage our clients to perform a roll down or body scan exercise so we can more accurately gauge any postural deviations. This body scan as listed in the BASI study guide manual provides an opportunity for the clients to focus and center themselves and serves as a pre- warm up and a post- cool down. At the same time it provides an opportunity for the instructor to assess the client s alignment and offer valuable input and correction. We watch them from all angles so we can see what their alignment is like.
I believe we can add a few additional movement observations tools to the list in addition to the body scan roll down. - I think we should also test the client s ankle, knee, leg and hip flexibility by asking them to squat as far down as they can before they need to lift their heels off the floor. Some people may have great ease with this movement, and other (like myself) may have extreme difficulty when performing this movement and even remark of hip pain when asked to go down too far. We can ask them to do this movement two different ways, one with a narrow stance and one with a wider stance. Also, in both parallel and turned out positions of the hips, legs, knees, and feet. (As you can see from the two images above, these are two completely different squats!)
- In addition to the squatting exercise, having the person lie on the floor in a supine position, heels on the floor, knees bent and then ask the client to let the knees drop open to determine turn out as well. This will help us analyze their rotation the hip socket so later when we are doing exercises like leg circles with them we have a better idea of their ROM at the hip joint. - There are many of additional movement exercises and tools that could be used to observe your client before you begin training with them, however by adding the two movement activities listed above you will have a more complete picture of not only your client s posture, but also their hip flexibility and ROM.
CONDITIONING PROGRAM FOR YOUR CLIENT WITH TIGHT HIPS: Based on the BASI Block System as the guide to the Pilates workout for Anna. - First Session- Observation & Introduction to Pilates: will include a 30min observation period and discussion with Anna about her movement patterns and abilities. She will be asked about any previous injuries, pains, goals, and will observed doing the three movement analysis tools listed above- the roll down, the squat, and the hip opener. During this time it is observed that Anna is not able to lower her pelvis down below the height of her knees. She feels a tightness and a burning pain sensation when she is asked to move into deep hip flexion. When she performs the hip opener movement tool she is observed to have a wide range in her turnout. It is concluded by her instructor that she needs to limit her range of motion when performing exercises in deep flexion and work more on her internal rotation and adductors since her external range of motion is so great. The second half of her session will be an introduction to the various pieces of equipment that she will using for her workouts including the mat, reformer, cadillac, and chair. She will first be instructed to find a neutral pelvis on the mat. She will be taught how to properly lift her chin and head up (looking through her legs) to avoid neck pain, she will be taught about lateral breathing, and engaging the belly button to spine. The instructor will lead her through a number of fundamental exercises to familiarize her with some of the movements and terminology of Pilates first on the mat. Mat Exercises- Pelvic Curl, Spine Twist Supine, Chest Lift, Hundred Prep, Hundred, Double Leg Stretch, Single Leg Stretch, Hamstring Pull 1, Roll Up, Roll Like a Ball, Roll Over, Open Leg Rocker, Leg Circles, Back Extension, Rest Position, ending with Push Up. (These exercises were chosen because many of them can be easily translated to the reformer. Also since this the client s first time, the goal is to focus on fundamental exercises and to avoid more difficult exercises like the Teaser, which might place undo stress on Anna s hip flexors.)
2-10th Sessions with Anna on the Reformer- Now that Anna has learned the Pilates basics, it s time to start her on the reformer. This second session will be an introduction to this new piece of equipment so once again the goal is to start with the fundamentals for her. She will then continue through ten sessions building on her knowledge and awareness of using the reformer. Reformer Exercises: Before she jumps on the reformer allow Anna to Warm Up and complete two roll down exercises using her deep inhales and exhales to jump start her breathing and warm up her spine. Moving into Footwork using two red springs- Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Prances, Single Leg Heel, Single Leg Toes. (Watching Anna s hip alignment during these activities. These will serve as a warm up for her feet, legs, knees, hips and abdominals before she has to engage her hips in bigger ROM exercises. Watch when she floats her leg off for single leg work that her leg is at 90degrees.) Abdominal Work- Hundred Prep, Hundred, Coordination, and Short Box Series. *Hip Work- Frog, Down Circles, Up Circles, Openings, Extended Frog, Extended Frog Reverse with a red and blue spring. (While working her Frog, make sure Anna only draws her legs back into 90degrees, not bringing her knees too far into her body during the repetitions. Also in Hip Circles, Openings, and Extended Frogs encourage Anna to take smaller ROM so that she does not pull or tear any of the muscles, ligaments, or tendons in and around her hips and legs. In both Leg Circles and Openings ask Anna to try these exercises in a turned in manner so that she can strengthen her internal rotators since her external rotators are already strong.) Spinal Articulation- Bottom Lift, Bottom Lift with Extensions, Short Spine, Long Spine with a red and blue spring.
*Next, in the Stretch Series, be extremely cautious here. These stretches can be excruciating and next to impossible with someone with a structural variation in their hip. Encourage Anna to start with the Standing Lunge but do not ask her to perform either the Kneeling Lunge or Standing Lunge. Those two stretches can put Anna at risk of injury. Full Body Integration- Scooter (use a light spring so Anna can focus on using her abs to draw the carriage in and not her leg muscles to push the carriage away.) Round Back, Flat Back, Elephant, Up Stretch 1, 2, and 3, Long Stretch, Reverse Knee Stretch, and Down Stretch. (Skipping the Stomach Massage Exercises to the extreme flexion of the hip that needs to occur.) Arm Work- Using one red spring or a red and a yellow, Anna will focus on higher reps at a less resistance to begin her arm workout with the Arms Supine Series. For the Arms Sitting series she will use one blue spring, and for Arms Kneeling Series she will use one blue spring. In the Side Arm Kneeling Series, Anna will begin with using one yellow spring and further along into her workouts, she will move up to one blue spring. Leg Work- Anna will stand up on the reformer to perform Single Leg Skating with one red and one yellow spring. (Watching her hips carefully to make sure she is working within her ROM. Make sure she is extending her leg and keeping her pelvis neutral and level, if her pelvis drops or tilts here, limit her ROM.) Back Extension- Breaststroke Prep, Breaststroke, Pulling Straps 1 & 2 all on one yellow spring. Lateral Flexion/Rotation- The Mermaid Exercise will allow Anna to conclude her workout with a nice side stretch and rotation stretch. (This is another exercise to watch Anna s hips in, she may not have the ability to lay both hips down on the carriage, her back leg may be less flexible in this rotated flexed sitting position.)
Sessions 11-20+ with Anna Additional exercises at the chair and cadillac will be incorporated into Anna s workouts. Her instructor will always keep in mind that certain exercises at these two pieces of equipment might be difficult for Anna s hip structure. For instance, a few exercises to be cautious of include: Footwork at the Cadillac (since the springs and resistance are sending the energy down into the hips, this could cause Anna some stress, use less resistance to avoid injury and make sure she does not bring her legs in too far towards her chest.) Hip Opener could be dangerous as well, proceed with caution. In Basic Leg Springs, Single Leg Supine, and Single Leg Side Series make sure Anna is working in a small ROM and keeping her pelvis stable and connected to the mat. At the chair make sure Anna has enough core strength to perform Foot Work well. Ensure Anna is using a lighter spring setting and limited range of motion when flexing at the hips. For the time being skip the Single Leg work at the chair, this exercise places a lot of stress on the front of her non- working leg. In Cat Stretch Kneeling, know that Anna might need to let her hips reach further back in space and may not be able to get them completely over her knees here. Full Pike and Side Pike are exercises where Anna may have some difficultly due to her in ability to deeply flex at the hips, she may not be able to flex as tightly as others and may need to let her upper body reach further away to allow her legs to float up in space. Both Frog Front and Back can also be a challenge for Anna, even though she has good external rotation, she does not have deep flexion, it may be extremely challenging for her to properly get into correct alignment here. Lastly, Forward Lunge and Backwards Step Down might also give Anna some difficulty due to her inability to get up and into those positions if she has a shallow hip socket. Allow her to use a spring setting which will help her do these exercises with ease, then as time progresses if she feels like she s built up the right muscles, you can try to change her spring setting.
CONCLUSION With a wide variety of BASI Pilates exercises to choose from at various pieces of equipment, it is always important to keep your client s body structure and ability in mind when designing a workout regime. By testing your client s posture and additionally ROM at the hips you will be able to better determine which repertory they need to be a little more cautious with. It is okay to allow your client to make compensations due to his or her ROM at the hips. Remember that every body is designed differently and each body moves differently. As a well- informed BASI Pilates Instructors it is our goal to ensure our clients are moving safely and in a healthy manner to avoid any further injury.
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