Pilates for ACL Rehabilitation

Pilates for ACL Rehabilitation Kristen Walsh Pollack October 8, 2016 Sherri (Berkeley, 2014)

ABSTRACT According to the New England Journal of Medicine, the ACL is the most commonly injured ligament in the body for which surgery is frequently performed (Spindler). Beyond the immediate pain and suffering a client experiences, they are far more likely to experience a second knee injury (Shelbourne) and premature knee osteoarthritis (Spindler). A well designed Pilates program should feel like a natural extension of the client s experience with their doctor and physical therapist. As sessions progress, the instructor should focus on building the muscles surrounding the knee (adductors, abductors, hamstrings and VMO) to create as much support as possible for the ACL and allowing the client live pain free with as much range of motion as possible. This paper articulates the case study of Christina P. and the accompanying Pilates conditioning program over an 8 month period. 1

TABLE OF CONTENTS i. Abstract 1 ii. Overview of the ACL 3 iii. Introduction 4 iv. Case Study 5 v. Conditioning Program 5 2

OVERVIEW OF THE ANTERIOR CRUCIATE (ACL) The knee joint is the meeting point of three bones - the femur, the tibia and the patella (i.e. the knee cap). The posterior edge of the femur and the anterior edge of the tibia widen at their meeting point to create stability in the knee (Calais-Germain, 211). The joint is held in place by two crudite or crossed ligaments, the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). Fig. 1 Bones of Knee Fig. 2. ACL and PCL While the PCL focuses on preventing the posterior displacement of the femur and tibia, the ACL resists the anterior displacement of these bones (Calais-Germain, 219). In a healthy knee, these two opposing ligaments work in opposition to keep the knee safe. Specifically, according to Butler, the ACL provides 85% of the restraining force at 30 degrees and 90 degrees of knee flexion. In addition, the ACL is responsible for: Preventing hyperextension of the knee; Limiting excessive internal and external rotation; Serving as a secondary restraint for valgus and varus stresses and; Enhancing the screw-home comes into terminal extension. 3

INTRODUCTION According to the New England Journal of Medicine, the ACL is the most commonly injured ligament in the body for which surgery is frequently performed (Spindler). In fact, Gammons sites that approximately 60,000-75,000 ACL reconstructions are performed annually in the United States (Gammons). ACL injuries are most likely to impact healthy and active teens and adults, and women are two to ten more likely to experience an ACL than their male counterparts, depending on the activity (see chart below). While there are several factors at play, research suggests that this caused by quadricep dominance and lesser hamstring strength, and neuromuscular adaptations and biomechanics related to landing techniques (Voskanian). During a ACL rupture, significant force is put on the knee causing it to twist and consequently snapping the ACL. Over 70% of ACL injuries occur in a non-contact situations, meaning there is no direct hit to the person s knee. As shown in the graph above, the majority of 4

injuries are from activities where multi-planar loading including anterior tibial shear, knee valgus and internal tibial rotation (Kiapour) are most likely to take place. This means athletes who play sports that require cutting and quick direction changes, such as basketball, soccer, football and skiing (as in the case study) are at a greater risk. CASE STUDY: CHRISTINA Christina P. is a 42-year-old Data Scientist who tore her ACL while skiing in 2015. After reconstructive ACL surgery, she completed a full course of Physical Therapy and received clearance from her PT and Doctor to begin a Pilates regime. While very active prior to her ACL injury, regularly practice Krav Maga, Christina had stopped all forms of exercise. She was no longer experiencing significant pain but had developed a lot of anxiety around movement involving her knee. Having taken a substantial break from exercise during her injury and rehabilitation time, I choose a progressive regime that allowed her to build strength and confidence. CONDITIONING PROGRAM Prior to beginning our first session, I did an extensive intake to understand the types of exercises she had worked on with her physical therapist and his recommendations for movement. The goal of our training sessions was to (1) build the muscles around her knee to help support movement, (2) establish a strong core and pelvic floor, and (3) develop the stabilization muscles such as the gluteus medius. 5

Block Session 1-5 Session 6-10 Warm Up Mat : Pelvic Curl Supine Spine Twist Chest Lift Chest Lift with Rotation Cadillac : Roll Down Mini Roll Ups Mini Oblique Roll Ups Roll Up Foot Work n/a Reformer : Foot Work Series Abdominal Work Mat : Hundred Prep Hundred Reformer : Hundred Coordination Hip Work n/a Hip Work Series Spinal Articulation Spine Stretch Bottom Lift (with ball between inner thighs) Stretches Standing Lunge Splits Full Body (Fund/Int) Elephant Elephant Up Stretch 1 Arm Work Supine Arm Series Kneeling Arm Series Full Body (Adv/Master) None None Leg Work Gluteal Side Lying Series Gluteal Kneeling Series + Adductor Lift with weights Lateral Flexion + Rotation Side Lifts Sideovers Back Extension Pulling Straps 1 & 2 Basic Swan One of most essential components of our training was the Warm Up. My focus with the Warm Up was to show her how to correctly engaged her abdominals. I started with a very basic warm of up of Pelvic Curls, Supine Spine Twist, Chest Lift and Chest Lift with Rotation because 6

it is a comprehensive set of exercises that helped Christina engaged her transverse abdominals (Pelvic Curls), obliques (Supine Twist and Chest Lift with Rotation) and rectus abdominus (Chest Lift). When we first began training together, we focused on the disassociation of her hip and ribs. Since she spent the majority of her timing sitting, she had very strong hip flexors that needed to be tamed to allow her to truly engaged her abdominals. As we progressed (see Sessions 6-10), I transitioned on to the Cadillac warm up. These exercises tested Christina s abdominal strength and ability to stay in neutral spine. In early sessions, I did not do classic Foot Work and chose to the engage the legs in the Leg Work block with the Gluteal Side Lying Series and then eventually adding weights. This was very effective in helping Christina to help her to equally engage her gluteus medius, adductors and abductors. In later sessions, after receiving clearance from her doctor and physical therapist, we began incorporating Foot Work on the Reformer, which I started on two red and one blue spring so as not to put too much pressure on her knee. I also utilized a ball between her inner thighs to help to keep her hips in alignment. When performing footwork, it was critical to ensure that Christina was correctly engaging her abductors, adductors, quadriceps, and that she was engaging her VMO but not hyperextending in her knee. Once Christina was able to maintain pelvic stability, I instructed her to do single leg footwork. Single leg footwork is especially beneficial to address imbalances and train both legs to work with equal force. For the Abdominal work block, in weeks 1-5, we worked on Hundred Prep and the Hundred on the Mat. I chose these exercises for a number of different reasons. Hundred Prep and Hundred are extremely effective abdominal exercises and helped Christina focus on trunk 7

stabilization. It also allowed for her to engage her legs without the added pressure of weight. Over time, we moved both exercises to the Reformer so we could incorporate Coordination. In the first couple of sessions, I chose not to teach Christina Hip Work based on the Pilates Method Alliance list of contraindications. Once she had strengthened her adductors, abductors and hamstrings, and received approval from her physical therapist, we began to incorporate the Hip Work block. We focused extensively on pelvic stability as her legs moved. This quickly progressed into one of Christina s favorite parts of the session and eventually was a nice progression into Short Spine. When considering Spinal Articulation, I wanted to create as much flexibility in her spine without putting pressure on her knee. I chose Spine Stretch to teach her how to articulate through each vertebrae while stretching her hamstrings. In later weeks, we began doing Bottom Lift with a ball between her inner thighs to keep her legs engaged and on her heels until she gained more strength. In these sessions, I was very careful to make sure her feet stayed in parallel as she tended to favor external rotation instead of properly engaging her adductors. For the Stretching block, once I confirmed Christina did not experience pain when putting any pressure on her knee, I had her do the Standing Lunge. As our sessions progressed, I instructed her to do a Kneeling Lunge. I find that it s more effective for hip flexor release based on the angle of the knee with the carriage and works well for clients with good hamstring flexibility. I also added in Splits; first with a block between her foot and the shoulder block and then in later sessions, we moved her foot over to the shoulder block. I find Splits to be a great exercise to engage the hip adductors, which helped to support her knee. 8

In the Full Body Integration block, I employed Elephant in week 1-5. As Christina became stronger and could more effective support her knee, I progressed her to Elephant and Upstretch 1. I chose these exercises because both are very effective to engage the legs, transverse abdominals and back extensors. Similarly, I started Christina on the Supine Arm Series and then began having her do the Kneeling Arms Series. I particularly like this arm series because it requires a lot of trunk and abdominal stabilization and move the arms in a controlled matter instead of trying to muscle through the exercises. After Leg Work, I moved on to the Lateral Flexion and Rotation block. Since Christina was particularly weak in her obliques, I had start with Side Lifts to engage all her core muscles. As our sessions progressed, we worked up to Sideovers on the Reformer which were very effective to create stability in her trunk. Because of the nature of her job and the amount of hours Christina spent sitting and working at a computer, back extension was especially crucial to correct her hyperlordosis. I chose Pulling Straps 1 and 2 because it is an extremely effective exercise to build the muscles in the back extensors. When teaching her, I focused heavily on the orientation of her arm in the shoulder socket so she was properly recruiting her triceps and stretching her pectoral muscles. As the muscles in her back developed, she was able to open up more and more through her chest, which allowed her to get into correct position for more advanced exercises like Tendon Stretch. ACL injury is an extremely serious and debilitating injury that impacts both physically and mentally. While carefully following the instruction of the client s doctor and physical therapist, a good pilates teacher can help the student to regain and further build the support muscles that can prevent a secondary injury to occur. Ultimately, Pilates allowed Christina to 9

experience a pain free existence while helping her to better understand the dynamics of her body and gain confidence. 10

Bibliography Calais-Germain, Blandine. Anatomy of Movement. 11th ed. Seattle, WA: Eastland P, 1991 Butler D, Noyes F, Grood E. Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Joint Surg Am, 1980. Gammons, Matthew. Anterior Cruciate Ligament Injury. Practice Essentials, Background, Frequency. Web. 3, Dec. 2016. Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, 2013. Kiapour, A.M. Basic science of anterior cruciate ligament injury and repair. Bone Joint Res., Feb 2014. Spindler KP, Huston LJ, Wright RW, et al. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. Am J Sports Med, 2011. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med, 2009. Voskanian, Natalie. ACL Injury prevention in female athletes: review of the literature and practical considerations in implementing an ACL prevention program. Curr Rev Musculoskelet Med, 2013. 11