Figuring how to work with a fractured figure skater

Hello Melanie! It’s Safia from Toronto.

I have a new regular client who is a figure skater. She primarily does pairs but is currently skating solo while searching for a new partner. She is 17 and has sustained a fractured ischial tuberosity on her right side and severe tendinitis in both ankles (now healed). She lands her jumps on her right leg. We’ve worked together 3 times so far and the last time I worked with her she strained her lower right back near her SI joint during the short spine on the reformer. I asked Sally to look at her quickly and she was the one who said it felt like her SI joint and the soft tissues that were aggravated. However, she has only ever experienced strain on her left SI joint – never her right before.
I did hip release with the mini stability (flex) ball and the mermaid for the rest of the session to help relieve the pain a bit. She took a break from figure skating that day but danced that evening since she had recitals on Friday and Saturday night (she does ballet).
I know I have to strengthen all the little muscles around her joints to help her learn to stabilize. I’m just wondering if you have any advice in terms of exercises to emphasize and also exercises to avoid (besides the short spine of course!!).
I hope you have a chance to come back to Toronto soon. It’s wonderful to have you in the studio!!
Take care and best wishes,

Safia

Response from Melanie:

Hi Safia!
Thank you for writing. With your permission, we will post this on the blog so that others can also learn from your great question.
 
What comes to mind immediately is the strength and control of your clients hip extensors, particularly the relationship of the deep hip rotators, the glutes and the hamstrings. I suspect that she does not have adequate eccentric control of her glutes, which would result in less control of her SIJ/ low back, more strain on her ankles and poor landing mechanics. For this, you would do exercises including (as able): shoulder bridge (prep and full)- progressing to single legged, and with feet on an unstable surface; side lying one leg pull on reformer- straight and bent leg; supine and side lying feet in springs on the cadillac; the step up and step down series on the chair; and of course plyometrics focusing on the landing. Other balance challenges such as fencers lunges on the cadillac would be beneficial.
 
For her ankles, make sure that you do a lot of ankle lower and lift on reformer and chair. Make sure you do a variety of positions (parallel, laterally and medially rotated in second), and at a variety of paces. Also do unilateral and weight shifting. Lower and lift in the sleeper position will help with lateral stability of the ankle and hip. Other things like standing on one leg while doing side arm series at the cadillac will help with balance and the tendonitis.
 
Other great exercises for a skater include arabesque, front and back splits, knees off knee stretches, and anything for the abs in extension.
 
I have not given you specifics for her SIJ so let me know if that did not resolve immediately and needs help.
 
I hope this helps. Let us know how you progress.
sincerely
Melanie Byford-Young

Herniated Disc Injury

This was emailed to us and we thought others might be interested!

Hi,
I wanted to ask about herniated disks. I have a client who has a herniated disk between L4 & L5, she does not currently have pain. Is it correct to not do any kind of lumbar flexion with thorasic rotation(i.e. short box round back with twist or mat obliques roll back), just rotation of thorasic with lumbar in neutral to avoid any further herniation?
Thanks,
Deanna Murray

Response from Leslie Braverman:

Hello Deanna:
Thanks for emailing. When the disc ruptures or herniates, a portion of the spinal disc pushes outside its normal boundary. When a herniated disc bulges out from between the vertebrae, the spinal nerves and/or spinal cord can become compressed. So depending on where this is happening will determine which movements to avoid. Typically, it is recommended that people avoid spinal flexion and rotation, because the disc most frequently herniates posterior-laterally and flexion and rotation would exacerbate the problem and/or create pain. To be perfectly sure which movements are to be avoided, it is best to speak with a physician or physical therapist that has worked with your client and has seen the notes from an MRI and knows exactly where the bulge is occurring. Unfortunately, as a pilates teacher, it is often hard to get this information.

If your client were still having a lot of pain, I would suggest that he/she consult with a doctor and, ideally, work with a physical therapist before doing pilates.

Since your client is no longer having pain it is possible that the disc problem has been resolved and the annulus is no longer irritable and pushing on the nerves. In this case, you can progress your client through all exercises and use her symptoms as a guide. Initially, be cautious of lumbar flexion and rotation. On the other hand, your client may have lost a lot of disc height and have too much segmental mobility and/or  instability where the disc was herniated. Progress slowly and be cautious of too much flexion load on her lumbar spine. Be very conscious of her ability to sit in neutral lumbar position. Most likely,  your client will need to sit on a box or cushion to have a proper position without stressing the lumbar area.

I would recommend that you focus your programming on work that encourages your client to become very stable in neutral positions. Really monitor what is happening at L4-L5. You may need to place your hand on her back to really be sure that she is not flexion or extending, even minutely, at this level. Often people with L4-L5 herniations will not know how to sit properly in neutral position, so really check that her lumbar and sacrum are absolutely correct.

Giving your client lots of exercising that challenge stability in neutral positions will be key to her avoiding future herniations or other deterioration of the spine. Here are some examples. Use these ideas with discretion-depending on the clients level and innate strength at this time- use your professional judgment:

1.) Cat position exercises- all variations to build stability in neutral:
-picking up one hand at a time
-sliding one leg out at at time
-alternating opposite arms and legs (i.e. swimming prep on hands and knees)

2.) Shoulder Bridges- Glut strength is paramount for people that have lower back instability
-advance to picking one leg up at a time
Make sure she is getting Glut medius and deep fibers of Glut Max- not just her deep rotators and hamstrings- watch she doesn’t tuck her sacrum under. Keep your hand on L4-L5 to maintain neutral.

3.) Leg Pull Front Prep

4.) Reformer- Footwork- keep your hand on L4-L5- maintain neutral

5.) Short Box- Straight back
You could do this on the reformer too with the arm straps (like roll back with a straight back) add bicep curls if able

6.) In kneeling positions, make sure that her hips are open enough to get head of femur over the knee so her spine can stay neutral. Her hips may be tight and not allow her to do this.

7.) Extension work is great- my guess is that it was a posterior herniation- if there is any pain avoid it. You can definitely do things like breast stroke that encourage upper back extension. If things like Swan Dive feel good, then do them. As usual, check that she is not hyper-extending at any one spinal level.

8.) Lateral flexion- watch alignment is excellent.

Hopefully, this gives you some good ideas. Challenge her in standing, kneeling and sitting positions- as long as there is no pain. Add upper body and lower body resistances to challenge her ability to stabilize her back against rotational pulls. Side lying work would be great too.

Then, once she is really strong this way, I would begin to introduce more flexion and rotation. Make sure that she is getting movement in all segments of the spine, and she is distributing and translating movement throughout the spine and not giving in at one level.

Some clients will fully recover from disc issues and some will always have a degree of vulnerability. You will have to find out slowly over time and with thoughtful progressions. When in doubt, be open to consult with your clients’ other health advisors and clinicians.

I hope this helps!

Best, Leslie Braverman

Where Are All The Men?

This was emailed to us and we thought others might be interested!

Six months on I have learned a lot more about Pilates, its benefits and limitations. One thing remains consistent in that it is unpopular with men. I do hear more openness towards it and a better understanding of what it is but there remains an unfortunate reluctance to participate. I started Pilates to improve my flexibility and to engage in a new practice that would drive me to challenge myself to think differently and learn new skills. I believe I have been very successful on both fronts. I’ve found some measures of flexibility which show me how much I have been able to improve my hamstring flexibility but more important than any measure is the feeling I get after working out. I come away with a feeling of lightness in the back of my legs up through my back which is wonderful and it illustrates to me I had no idea how my inflexibility felt. This is akin to the feeling of the frog that is being slowly boiled and doesn’t recognize the gradual increasing of the water temperature.

The biggest surprise for me came the morning after I started playing indoor soccer again after a gap of several years. I expected to be extremely stiff and too my surprise I felt great with no stiffness at all. Now that doesn’t mean I am in great shape, aerobically the soccer kicked my butt, big time! I had hoped I could use jump boarding to maintain my aerobic fitness but I’ve concluded I need to do more aerobic work beyond Pilates. The other disappointment is that my left knee was unable to take the strain of twisting and turning and so that’s the end of my indoor soccer season. If I had started Pilates 10 or even 20 years ago I would have learned that the biomechanics of my knee movement puts strain on the outside of my knees and I wouldn’t have worn away the meniscus on the outside of my left knee. I did not realize Pilates focuses on proper biomechanics as well as developing strength and flexibility. I can only look back at what might have been had I started Pilates earlier!

Back to my observation that men are not engaging more actively in Pilates, given my experience above, this is disappointing as learning how to use your body more effectively could be a huge benefit to young athletes and in reality all of us. I was encouraged listening to a radio interview with one of the Portland Trailblazers staff that Brandon Roy will be focusing on Pilates and Yoga this summer. Brandon wants to develop the ability to be stronger and tougher and was looking to do more weight training and instead the Trailblazers coaches have convinced him to focus on strengthening his core and improving his agility. I expect to see an even stronger and faster Brandon Roy next season.

As for myself, I’ll keep on working on my Pilates practice and keeping my female classmates amused, I hope I’m not slowing you down too much. Maybe I’ll be successful in convincing one or two male friends but if I don’t it will be their loss and I’ll continue to enjoy my all female company.

I would love to hear your views why Pilates is not more popular with men or why you enjoy it and what you have got out of it.

Andy Robbins