Download pilates for injury prevention: decreasing knee joint laxity

PILATES FOR INJURY PREVENTION:
DECREASING KNEE JOINT LAXITY
Prepared By
Claire Lieberum
September 2014
La Playa Pilates and Wellness Center
Santa Barbara, CA
ABSTRACT
Knee pain and knee injuries are a common occurrence in people of all ages (1). This paper
will explore the positive effects of a Body Arts and Science InternationalTM based Pilates program on
a smaller population, the young and active. Statistics show that knee injuries represent nearly 15% of
all sports injuries. Due to the significance of the knee to daily function, and likely cause of disability
from injury, 50% of visits to sports doctors are focused on the knee (2). In this case study, the
participant presents with bilateral Genu Recurvatum and minor knee pain. She committed to an
intensive 10 week (3 times per week) Pilates program and was extremely pleased with the results.
Improvement in knee stability, decrease in the severity of the genu recurvatum as well as significant
improvement in body awareness during activity all presented following her training.
TABLE OF CONTENTS
I.
Anatomy of the Knee………………………………………………………………… 4
II.
Introduction…………………………………………………………………………... 6
III.
Case Study…………………………………………………………………………….. 7
IV.
Conditioning Program………………………………………………………………… 7
V.
Conclusion………………………………………………………………………….....11
VI.
Bibliography…………………………………………………………………………. 12
JOINT STRUCTURE OF THE KNEE
The knee is the largest joint in the body yet one of the most easily injured. It is a complex
joint with many components and therefore has a multitude of parts that are at risk for strain, sprain,
dislocation, fractures and tears (3,6).
The knee is made up of four bones: the femur, the
tibia, the fibula and the patella (kneecap). The joint
is a synovial hinge joint that allows the lower leg to
move relative to the thigh while supporting the
weight of the body. As with all synovial joints, a
joint capsule surrounds the bones of the knee to
provide strength and lubrication. Ligaments
surround the joint capsule and act to reinforce its
structure holding the bones in proper alignment
(5). At the anterior surface of the knee, the patella is held in place by the patellar ligament. To
prevent the femur from sliding medially and laterally, the medial and lateral collateral ligaments
support the sides of the joint. Internally, the anterior cruciate ligament (ACL) prevents the femur
from sliding backward on the tibia, while the posterior cruciate ligament (PCL) prevents the femur
from sliding forward on the tibia. Two C-shaped pieces of cartilage called the medial and lateral
menisci act as shock absorbers between the femur and tibia. Small pockets of synovial fluid, known
as bursae, surround the knee to reduce the friction from movement of tendons across the surface of
the joint (5,6).
MUSCLES OF THE KNEE
The muscles that create movement of the knee joint are the hamstrings, the quadriceps and the calf
muscles. The four muscles of the quadriceps (vastus lateralis, vastus medialis, vastus intermedius,
and rectus femoris) act together to create knee extension. Posteriorly, the hamstrings (biceps
femoris, semitendinosus, and semimembranosus) work to cause knee flexion along with the
gastrocnemius of the calf (4).
INTRODUCTION
Knee problems are very common, and they occur in people of all ages. Knee pain and knee
injuries can interfere significantly with a person’s quality of life, inhibiting a wide range of activities
from participation in sports to simply getting up from a chair and walking. The knee joint faces
certain challenges: it must be fairly flexible to allow for movement while at the same time, it needs to
offer stability and support while standing (8). Knee stability comes from three elements: the
structure of the bones, the structure of the ligaments/capsule and the strength of the muscle groups
which act on the knee (2). If any of these are deficient due to injury or instability, a person will tend
to have ongoing knee problems.
Instability of the knee may present with any of the following mechanical symptoms: locking,
catching, clicking, or giving way, particularly with twisting movements (10). In the young and active
population (a group that typically presents with healthy bone structure) it is important to strengthen
the musculature of the knee in order to eliminate pain and keep knees safe from future injuries.
According to Jordan D. Metzl, MD, sports medicine physician at the Hospital for Special Surgery in
New York City, “when the surrounding muscles are strong, they take pressure off the joints, which
allows for greater activity with fewer aches and pains” (11). In cooperation with a strengthening
program, it is important to also include a flexibility program (9). Supple, well-stretched muscles are
less prone to injury, while less flexible muscles and connective tissues restrict joint mobility, which
increases the likelihood of sprains and strains (12).
CASE STUDY
Name: Sarah* (name has been changed for the privacy of the client) Age: 26
History: Sarah is a fitness instructor with no background of acute knee injury. She presents with
minor knee pain and self-proclaimed “weak knees”. Sarah teaches on average 20 exercise classes per
week where she must jog, jump, squat, and lunge on a concrete surface. She is concerned that the
instability in her knees may result in injury which could possibly result in joblessness. She was a
competitive swimmer for 12 years and stated that her knee pain was present at that time as well.
Initial assessment found bilateral Genu Recurvatum (hyperextension of the knees) as well as an
imbalance between the quadriceps and hamstrings. Sarah’s hyperextension was previously measured
by a Physical Therapist at 15 degrees.
CONDITIONING PROGRAM
Sarah committed to attending Pilates sessions 3 times per week for 10 weeks. Her program was
designed utilizing the Body Arts and Science InternationalTM Block system. Within this system,
emphasis was placed on strengthening the hamstrings as well as the surrounding muscles that
provide knee joint stability. In addition to working on the musculature of the knees, Sarah was also
introduced to the 10 Principles of Pilates. Focus was placed on precision of movements and balance
between muscle groups. The following are examples of 2 workouts that Sarah was given throughout
her 10 week program.
WEEK 2
WARM-UP (PERFORMED ON MAT)
Exercise
Muscle Focus
Objectives for Client
Roll Down
Total Body
Body awareness, focus and hamstring stretch
Pelvic Curl
Hamstrings, Abdominals
Warm -up with focus on hamstring control
Spine Twist Supine
Abdominals
Abdominal warm-up, control of tabletop position
Single Leg lift
Abdominals
Abdominal warm-up, control of knee joint angle while moving at hip
Leg Circles
Abdominals
Abdominal warm- up, control of knee joint in extension
Notes: In Roll Down, down position was held for 15 seconds each rep to allow for increased hamstring stretch in preparation for
exercises. Leg Circles were performed with slight bend in knee due to client's tight hamstrings.
FOOT WORK (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Parallel Heels
Hamstrings, Quadriceps
Knee flexor and extensor co-activation and strength, Hip extensor strength
Parallel Toes
Hamstrings, Quadriceps
Knee flexor and extensor co-activation and strength, Hip extensor strength
V Position Toes
Hamstrings, Quadriceps
Knee flexor and extensor co-activation and strength, Hip extensor strength
Open V Heels
Hamstrings, Quadriceps
Knee flexor and extensor co-activation and strength, Hip extensor strength
Open V Toes
Hamstrings, Quadriceps
Knee flexor and extensor co-activation and strength, Hip extensor strength
Calf Raises
Ankle plantar flexors
Calf strength, control of knee joint without Hyperextension
Prances
Ankle plantar flexors
Calf strength and stretch, control of knee joint without Hyperextension
Notes: Foot work was performed on medium resistance (3 red springs) to allow for increased focus on hamstring activation.
Adductor activation and proper leg alignment were emphasized by using a soft ball between knees.
Open position foot work was performed in parallel versus external rotation as client's relaxed stance is in ER and internal rotators need
strengthening. Calf work performed slowly with "soft knees".
ABDOMINAL WORK (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Hundred Prep
Abdominals
Abdominal strength, Hip/Knee flexion and extension control
Notes: Each rep was performed with extension of the knees and then flexion back to tabletop position.
HIP WORK (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Frog
Hip adductors
Hamstrings and Hip
adductors
Hamstrings and Hip
adductors
Hip adductor strength and Knee extensor control
Circles Down/Up
Openings
Hip adductor strength and Knee extensor control
Hip adductor strength and Knee extensor control
Notes: Circles and Openings were performed with slight bend in knee due to client's bias toward hyperextension.
STRETCHES (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Standing Lunge
Hip flexors, Hamstrings
Hip flexor and Hamstring stretch
Notes: Held positions for 5 breath cycles.
ARM WORK (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Arms Supine Series
Latissimus Dorsi, Triceps
Balance in workout, Hip and Knee control in tabletop position
LEG WORK (PERFORMED ON MAT WITH MAGIC CIRCLE)
Exercise
Muscle Focus
Objectives for Client
Ankles Bent Knees
Hip adductors and extensors
Hip adductor and extensor strength
Notes: Performed in prone position with emphasis on Hamstring control.
LATERAL FLEXION/ROTATION (PERFORMED ON MAT)
Exercise
Muscle Focus
Objectives for Client
Side lifts
Abdominal Obliques
Trunk stabilization with adductor control
BACK EXTENSION (PERFORMED ON MAT)
Exercise
Muscle Focus
Objectives for Client
Back Extension
Back extensors
Balance in workout, back extensor strength
Notes: Followed by rest position and final roll down for Hamstring stretch and body awareness.
WEEK 5
WARM-UP (PERFORMED ON CADILLAC USED AS MAT)
Exercise
Muscle Focus
Objectives for Client
Roll Down
Total Body
Body awareness, focus and hamstring stretch
Pelvic Curl
Hamstrings, Abdominals
Warm -up with focus on hamstring control
Spine Twist Supine
Abdominals
Abdominal warm-up, control of tabletop position
Leg Changes
Abdominals
Abdominal warm-up, control of knee joint angle while moving at hip
Leg Circles
Abdominals
Abdominal warm- up, control of knee joint in extension
Notes: In Roll Down, down position was held for 15 seconds each rep to allow for increased hamstring stretch in preparation for
exercises. Leg circles were performed with straight leg as client has progressed.
FOOT WORK (PERFORMED ON CADILLAC)
Exercise
Muscle Focus
Objectives for Client
Parallel Heels
Hamstrings
Hamstring strength and stretch, Knee extensor strength
Parallel Toes
Hamstrings
Hamstring strength and stretch, Knee extensor strength
V Position Toes
Hamstrings
Hamstring strength and stretch, Knee extensor strength, adductor control
Open V Heels
Hamstrings
Hamstring strength and stretch, Knee extensor strength, adductor control
Open V Toes
Hamstrings
Hamstring strength and stretch, Knee extensor strength, adductor control
Calf Raises
Ankle plantar flexors
Calf strength, control of knee joint without Hyperextension
Prances
Ankle plantar flexors
Calf strength and stretch, control of knee joint without Hyperextension
Single Leg Heel
Hamstrings
Hamstring strength and stretch, Knee extensor strength
Single Leg Toes
Hamstrings
Hamstring strength and stretch, Knee extensor strength
Notes: Foot work performed slowly with focus on co-activation of leg muscles, control and awareness.
ABDOMINAL WORK (PERFORMED ON CADILLAC USED AS MAT) (MC= Magic Circle)
Exercise
Muscle Focus
Objectives for Client
Chest Lift (+MC)
Abdominals, Hip adductors
Abdominal strength, Hip adductor strength
Single Leg Stretch
Abdominals
Abdominal strength, control of knee extension
Hamstring Pull 1
Abdominals
Abdominal strength, Hamstring stretch
HIP WORK (PERFORMED ON CADILLAC)
Exercise
Muscle Focus
Objectives for Client
Frog
Hip adductors
Hip adductor strength and Knee extensor control
Circles Down/Up
Hamstrings
Hip extensor strength and adductor control
Walking
Hamstrings
Hamstring control
Notes: Circles and Walking performed with slight bend in knee due to client's bias toward hyperextension.
SPINAL ARTICULATION (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Bottom Lift
Abdominals, Hamstrings
Hamstring control and strength
Notes: Started client with heels on footbar due to hamstring weakness.
STRETCHES (PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Standing Lunge
Hip flexors, Hamstrings
Hip flexor and Hamstring stretch
Notes: Held positions for 5 breath cycles.
FULL BODY INTEGRATION (FUNDAMENTAL/INTERMEDIATE)(PERFORMED ON REFORMER)
Exercise
Muscle Focus
Objectives for Client
Scooter
Abdominals
Hip and Knee extensor control/strength
ARM WORK (PERFORMED ON REFORMER)
Exercise
Arms sitting series
Muscle Focus
Latissimus Dorsi, Biceps,
Deltoids, Pectorals, Triceps
Objectives for Client
Trunk Stabilization
Notes: Advanced client to Intermediate arm work early due to strength, ability and control during supine arm work.
LEG WORK (PERFORMED ON CADILLAC AS MAT, WITH MAGIC CIRCLE)
Exercise
Objectives for Client
Ankles Straight Knees
Muscle Focus
Hip adductors and
extensors
Hamstrings
Hamstrings and Gluteals
Knee flexor strength, Hip extensor strength
Hip adductor and extensor strength
Notes: Exercises done in prone position with emphasis on Hamstring control.
LATERAL FLEXION/ROTATION (PERFORMED ON CADILLAC AS MAT)
Exercise
Muscle Focus
Objectives for Client
Saw
Hamstrings
Hamstring stretch, Back extensor control, Oblique control
Exercise
Muscle Focus
Objectives for Client
Back Extension
Back extensors
Balance in workout, back extensor strength
BACK EXTENSION
Notes: Followed by rest position and final roll down for Hamstring stretch and body awareness.
RESULTS: Following her 10 week program, Sarah stated that she noticed a significant difference in
the stability of her knees while teaching as well as decrease in knee pain. She expressed that she is
much more aware of her movements and has a greater focus towards proper muscle recruitment in
her work and daily life. Not only was there improvement in knee stability, but after hamstring
strengthening a decrease in the severity of the genu recurvatum was achieved. Sarah is still able to
reach hyperextension in the joint, yet states that the stance “feels uncomfortable”. She also states
that she feels stronger as a whole and has become “addicted” to Pilates.
CONCLUSION
Knee instability remains one of the main factors in knee pain and potential for injury. As
shown by this case study, decrease in the severity of joint laxity and muscle imbalance can occur
with a proper stretching and strengthening program. The comprehensive Block System from
BASITM Pilates was imperative in helping Sarah to gain stability and confidence in the use of her
previously “weak knees”. As in the case with Sarah, a comprehensive Pilates program not only is
able to address muscle imbalances in weak areas of the body but will strengthen the body and mind
as a whole.
BIBLIOGRAPHY
1. Mayo Clinic Staff. Diseases and conditions, Knee Pain. 29 March 2013.
http://www.mayoclinic.org/diseases-conditions/knee-pain/basics/definition/con20029534
2. McGlaughlin, Ed, MD. Knee Injuries. http://www.sportsmed.info/sportsmed/knee.html
3. Thayer, Matthew BSN, RNFA, ONC, CNOR.(Image)
http://www.christuslivewell.org/what-hurts-less-a-total-knee-replacement-or-a-total-hipreplacement-surgery/
4. Knee Joint Muscles. http://www.sportsinjuryclinic.net/anatomy/human-muscles/knee-joint
5. Taylor, Tim. (Image)Knee Joint. http://www.innerbody.com/image/skel16.html
6. Knee Pain Health Center. http://www.webmd.com/pain-management/knee-pain/picture-ofthe-knee
7. Knee Muscles.(Image) http://kneeexercises.net/knee-muscles/
8. Knee joint function. http://www.ivysportsmed.com/en/knee-pain/knee-joint-function
9. Tis, Laurie Ph.D., FACSM. 10 January 2012. Basic Knee Injury Prevention.
http://www.acsm.org/access-public-information/articles/2012/01/10/basic-knee-injuryprevention
10. Kakarlapudi, Trinath and Bickerstaff, Derek. “Knee instability: isolated and complex.”
British Journal of Sports Medicine 2000;34:394-400
11. Stanten, Michele. “Best and Worst Exercises for Bad Knees.” Prevention November 2011.
http://www.prevention.com/health/health-concerns/exercises-knee-pain
12. Stretching and strengthening are key to healing and preventing back pain. 30 January 2014.
http://www.health.harvard.edu/healthbeat/stretching-and-strengthening-are-key-tohealing-and-preventing-back-pain