Pilates for an Endurance Triathlete with special focus on Achilles Tendonitis and Posterior Tibialis Tendonitis Danielina Snyman June 7, 2014 CTTC 2014 Chicago, Il
Abstract Triathlon is a physical demanding sport. Triathletes spend a lot of time on their feet for running and a lot of time in their saddle for cycling. Running and cycling is great for fitness and benefits your cardiovascular endurance tremendously, however, it can also put a lot of stress on your feet, legs, hamstrings and gluteals. This can trigger any previous injury or if you should have any underlying biomechanical problems or compensations in your gait cycle it can lead to injuries or result in pain. This paper will explore the reasons how Achilles Tendonitis and Posterior Tibialis Tendonitis occur and how it can be improved, strengthened and resolved with Pilates training. 2
Table of Contents Abstract 2 Anatomy and Biomechanics 4 Case Study 7 BASI Pilates Conditioning Program 9 Conclusion 13 References 13 3
Anatomy and Biomechanics http://www.tptherapy.com/unlock- your- body- anatomy- foot- lower- leg.html http://taoknitter.com/2007/07/31/dancing- calves/ 4
http://www.tptherapy.com/unlock- your- body- anatomy- foot- lower- leg.html The feet are our base of support. If our alignment is incorrect it will influence our base of support. It won t be very stable and it can lead to pain, compensations or injuries. The feet provide support when running and it s the foundation for the body s integrity and movement. When we address problems 5
concerning the feet we should look at ligaments, tendons and muscles which stabilizes the ankle- foot complex. The Achilles tendon is the largest tendon in the human body. It attaches the gastrocnemius and the soleus to the calcaneus. The muscle mass and strength of the gastrocnemius and soleus muscles are greater than any other muscle of the lower leg combined. These muscles pull on the Achilles tendon when running, jumping, walking etc. and put the Achilles tendon under a lot of stress and therefore it is prone to injury. The most common form of injury for the Achilles tendon is called Achilles tendinitis. It can either be acute or chronic. The Achilles tendon get inflamed and cause a lot of pain and discomfort. It will be felt especially with plantar flexion and extreme dorsiflexion. Recovery is a slow process because of the limited blood supply and the underlying biomechanical problems, such as excessive pronation, limited range of motion in dorsiflexion, muscle imbalances and poor running mechanics. The posterior tibial tendon runs down the back of the leg (not far from the Achilles tendon), behind the inside medial malleolus, across the instep and into the bottom of the foot, to support the arch of the foot and help turn the foot inward during walking or running When the posterior tibialis tendon gets inflamed it will usually be felt on the inside of the foot. Once again this could happen because of various 6
biomechanical problems. This area of the tendon that wraps just underneath the medial malleolus is prone to a lot of problems because of the lack of blood supply, the body has difficulty delivering the proper nutrients for healing. Introduction When doing a triathlon the triathlete would come straight out of the water after the swim and transition to the bike for cycling, after cycling the triathlete would then transition to running. There is no resting in between and you are trying to get out of the transition area as fast as possible. When doing a half ironman you would race on average 5-6 hours and when doing a full ironman you would race for 9-12 hours. These distances put tremendous strain on the body. When you come out of the water and you get on you bike you prepare yourself to ride for more than 3hours. When cycling you are using all your lower limbs. Your quads are overloading, your hamstrings are working hard, your gastrocnemius and soleus are pulling and pushing and in turn a lot of stress will be put on your Achilles tendon. After cycling for a minimum of 3 hours you transition straight to your running. The running is the last leg of the race and your body by then is fatigued. The running would be a minimum of a half marathon or a maximum of a full marathon. You must be able to keep an upright posture for a long period of time. It requires core strength and endurance in postural muscles of abdominals and 7
upper back. If you should have any compensations in your gait cycle they will definitely play a big roll in the run. Achilles tendonitis could take place because of intrinsic and extrinsic factors. Structural alignments, muscle and joint stiffness, concentric and eccentric strength, training errors, running surfaces and footwear. In this case study we will use Pilates training to improve the biomechanical problems to improve dorsiflexion, strengthen posterior tibialis (and overall foot muscles strength), strengthen gluteus medius and minimus to prevent knee from rolling in, stretch and strengthen hamstrings and external rotators, strengthen and stretch gastrocnemius and soleus so that they can resist against force and allow proper ankle joint and subtalar joint mobility. Case Study My case study is Jaco Conradie, he is 30 years old, an actuary (so has a job where he sits in front of a computer the whole day), a endurance triathlete and also my husband. He trains 6 days a week twice a day. It is a mixture of two of the three sports daily: swimming, cycling and running. He has done some Pilates using the equipment, but does not have a lot of experience in Pilates. He has tight hamstrings, calves muscles and pain in the right Achilles tendon. After a long run recently he complained about a lot of pain in the inside of his foot, under his arch. The physical therapist said it was because of weak posterior 8
tibialis tendon. He hopes that the Pilates training will strengthen foot and ankle muscles and tendons, improve overall flexibility in joints and muscles, strengthen his core so that he can minimize his susceptibility for injuries. While doing the roll down I did not see restrictions in the sagittal plane or plumb line. I did, however, notice some restriction in his hamstrings and his right side of his back in the coronal plane. Pilates Conditioning Program Following are a typical example of a session on the Pilates equipment. The aim was to do 8-10 sessions so that we could see if we are progressing in overall strength and flexibility while he still do his training without further injuring himself. * Roll down Reason: To record any deviations. * Warm up Puppet arms Pelvic curl Supine spine twist Chest lift Chest lift with rotation Reason: Fundamental exercises for opening the chest, spinal articulation, rotation, flexion and deep abdominal strengthening. Result: To prepare body for next block in the program, to follow a breathing pattern, to build abdominal strength * Foot work (Reformer) Parallel heels and toes V- position toes Reason: To warm- up the lower limbs, emphasizing on hamstring, quadriceps and ankle plantar flexion strength and 9
Open v- position heels and toes Calf raises Prances Prehensile Single leg heels and toes stretching. Result: To initiate movement with hamstrings, to do eccentric contraction during calf raises and prances. Will stretch calves a bit longer after prehensile. * Abdominal work (Cadillac) Mini- roll up Mini- roll up oblique Roll up bottom loaded Reason: To strengthen abdominals and focus on oblique s for better core strength. Result: This will strengthen his core and help him to maintain his posture during running. Adding the resistant s will help him to work a bit harder and deeper on abdominal strength. * Hip work (Reformer) Frog Circles down Circles up Openings Reason: Use full range of motion of hips. Activate external rotators hamstrings and hip adductors. Result: To initiate movement with hamstrings, to strengthen and stretch hip adductors. Must keep external rotators activated through out and pelvic lumbar stabilization. * Spinal Articulation (Reformer) Bottom lift Reason: To articulate through the spine one vertebrae at a time. To 10
Bottom lift with extension Short spine activate the core, stretching and strengthening the hamstrings and hip flexors. Results: Articulate through the spine for spinal mobility. To keep hamstrings activated for strengthening and stretching hip flexors. Stretching hamstrings, lumbar and using deep abdominal strength for control. * Stretches (Reformer) Kneeling lunge Reason and result: To stretch hip flexor and hamstrings, which shorten a lot during running. * Full Body Integration (F/I) (Reformer) Up stretch 1 Elephant Reason: To stretch hamstrings, co- contract abdominals and back extensors. Result: Lengthen hamstrings and using deep abdominal strength to draw legs in. Strengthening back extensors and working hard to extend back and stabilizing shoulders. * Arm work (Reformer) Arms kneeling series Chest expansion Circles up Reason: To stabilize the trunk while working arms against resistant s. Result: Need to keep trunk stabilized, core working and alignment while 11
Circles down Triceps Biceps * Leg work (Gluteal Side lying series) Side leg lifts Forward and lift Forward and drop arms are fatiguing. Building up endurance for running to keep core strong while fatiguing. Reason: To strengthen gluteus medius and minimus. Keep pelvic lumbar stabilization and a strong core. Result: Strengthening gluteus medius and minimus will keep hips from hiking or pelvis rotating during running. Which will prevent injuries. * Lateral Flexion/Rotation (Wunda Chair) Side stretch Reason: To strengthen abdominals with oblique emphasis. Result: To stretch lateral flexor, to maintain pelvic stabilization and strengthen abdominal oblique s. To help keep core strong during running. * Back Extension Swan basic (Wunda Chair) Cat stretch (Mat) Reason: To strengthen back extensors while still controlling abdominals and stretching lumbar spine. Result: To build back extensor endurance for running to keep alignment and core strong while fatiguing. To release lumbar spine which shorten during sitting (my client 12
has a desk job). Roll down Reason: To end the session, be in the moment and focus on breathing and relaxing. Conclusion Triathlon is a sport that puts a lot of pressure on the lower limbs and if there should be any gait deviations or underlying biomechanical problems it will lead to injury. Cross- training is crucial and Pilates definitely offers that. I have done a few sessions with Jaco and will continue to do more. His calves and ankle joints aren t so tight anymore and his core strength is improving. We have done extra foot exercises because of his high arched foot which seems to be weaker than expected. The strength in his feet has built up fast and this helps him to continue with his training and not get injured. He was able to embrace the mind- body connection and this has helped tremendously with his everyday activities. He does a good job maintaining the strength and stretching exercises to counter balance all the training. I will continue teaching Jaco and only expect more progress with each session. References Cassidy Phillips Biomechanical Specialist, Trigger Point Performance Therapy, http://www.tptherapy.com/unlock- your- body- anatomy- foot- lower- leg.htm Jonothan Cluett, M.D. (May 30, 2014), Posterior Tibial Tendonitis, http://orthopedics.about.com/cs/footproblems/a/posteriortibial.htm 13
Dr. Ray McClanahan, (2014), Northwest Foot & Ankle Achilles Tendonitis https://nwfootankle.com/foot- health/drill/3- problems/36- tendinitis BASI CTTC Study Guide, 2013. BASI Mat Movement Analysis Workbook, 2012 BASI Reformer Movement Analysis Workbook, 2012. BASI Wunda Chair Movement Analysis Workbook, 2012. BASI Cadillac Analysis Workbook, 2012. Munteanu, S.E. and Barton, C.J. (2011). Lower limb biomechanics during running in individuals with Achilles tendinopathy: Journal of Foot and Ankle Research (4:15). Achilles Tendinitis, Great Lakes Foot & Ankle Centers, Kenneth W. Oglesby, D.P.M., Mass. John M. Giurini, D.P.M., Chief, Division of Podiatry, Assistant Clinical Professor of surgery, Harvard Medical School, Boston, Mass. http://greatlakesfootankle.com/treatments- list/ Posterior Tibial Tendon Dysfunction (PTTD), American College of Foot and Ankle Surgeons, 2013 http://www.foothealthfacts.org/footankleinfo/pttd.htm Posterior Tibial Tendinopathy, Teresa Briedwell, PT, DPT, OCS, 2014 EBSCO Publishing http://medicine.med.nyu.edu/conditions- we- treat/conditions/posterior- tibial- tendinopathy Pilates for Ultrarunners with Special Focus on Achilles Injury Prevention, Nicole Giumarra February 22, 2014 http://www.basipilates.com/lib/file/pilates- for- ultrarunners- with- special- focus- on- achilles- injury- prevention.pdf Lower Limb Kinematics of Subjects with chronic Achilles Tendon Injury during Running. Taylor & Francis Group, LLC, 2008 http://www.oliverfinlay.com/assets/pdf 14