Knee Stability Post Surgery

We just got this question emailed to us from a student:

This is Christi Tuck from Colorado Springs YMCA. I am a certified STOTT PILATES instructor and I have a question.
I have an inquiry from a possible student regarding some knee issues and if the reformer would be beneficial and are their any concerns. Basically they had surgery recently and the doctor informed them they have no cartilage around the knee. I believe they had the meniscus repaired.
My guess is the reformer would be helpful to strengthen the surrounding muscles and that starting at light resistance would be best. I welcome any comments or suggestions.

Hi Christi-
Thanks so much for your question. As far as your client’s issues are concerned; yes, the reformer would be very beneficial to her recovery. Doing footwork starting with lighter resistance is a great start. I would also do single leg pulses in a variety of positions–laterally rotated, parallel and medially rotated. Make sure when she is doing footwork or single leg that she is really using her quads to draw the kneecap up as she straightens the leg. VMO (vastus medialis oblique) is especially important for knee stabilization and it tends to be weak for many women. I find I really feel the VMO muscle more when doing lateral knee pulses, but that may vary from person to person, so check in with her to see if she is feeling that muscle. Strengthening the posterior leg muscles will also help to stabilize the knees, so make sure you are doing some glute and hamstring work as well.
Melanie Byford-Young has a great workshop on Knee Stabilization if you ever get a chance to take it! She created an exercise where you are sitting on the reformer carriage with no springs attached. One foot is on the floor between the rails and the other leg is lifted up supported by the hands or with a flexband around the thigh. If you have a rotational disc, place the foot on top of the disc and keep the ankle, knee and hip tracking as they slowly move the carriage out and in. This helps to stimulate and strengthen the popliteus muscle which is another deep knee stabilizer.
The more those stabilizing muscles are activated and strengthened, the less wear and tear will occur to the knee and the remaining cartilage. Eventually, you can increase the resistance as those muscles get stronger, but at the beginning we don’t want to overload those stabilizing muscles.
Let me know how things go or if you have any other questions.

Ischial Bursitis

Hi Melanie!
 
I recently attended your gait seminars in May, and wanted to relay to you that my clients are absolutely loving the work and the results.  Thank you so very much!
 
If possible, I would so appreciate your input relative to ischitis or ischial bursitis.  Recently, two clients have been referred to me with this diagnosis, one of which has a R hip replacement, L knee replacement, and its the L ischium that’s affected.  Both clients spend too many hours at desk and chair, likely sitting behind their sitzbones.  I’ve referred both to a PT for cranial/visceral work to hopefully release the area of the coccyx. 
 
Naturally, they have hip flexor hypertonicity, but because of their symptomology I avoid hip extension and work only within their comfort range in neutral pelvis/spine.  Any “pearls of wisdom” you could share with me, would be hugely appreciated! 
 
Thank you very much, and I look forwarding to seeing you again soon!
 
Best,
 
Tina Strickland, LMT
Stott Pilates Certified Instructor

Response from Melanie:

Hi Tina!
Ischial bursitis is an interesting and complicated issue to help resolve. Things that characteristically contribute to, or leads to ischial problems include: hamstring dominance over the gluteals/deep rotators, stiffness of the feet or ankles, poor positioning of the pelvis (either anterior or posterior rotation) which places the hip adductors and gluteals in a position of inefficiency, and lumbar spine problems.
Developing gluteal strength in the presence of a hip replacement can be tricky. We like to lie such a client prone over the cadillac or ladder barrel and work on hip extension there where the gluteals are working in midrange. Start out by assisting with the concentric lifting of the leg, make sure that the glutes are set, then have the client control the lowering. Assist as much as required so that the client does not experience the ischial pain.
Try to develop as much ankle and foot mobility as possible. Your client requires the full 20 degrees of ankle dorsiflexion to be able to walk normally and not have to alter the hip to compensate.
See how these ideas work and report back to us.
good luck!
Melanie Byford-Young

Osteiitis Pubis

Hi Melanie
Sorry to seek your assistance so soon again.  If you can find the time to give me some help on this client would again be very grateful.
 
One of my clients has  has osteitis pubis.  She has now had this for 2 years, bought on in her second pregnancy.  She played hockey upto 14/15 weeks of this pregnancy.  She had no pain at that time, but did in the later stages of her pregnancy.  Unfortunately, she didn’t say anything about the pain to her midwife and no pelvic support was used.  After the birth, she pushed herself quite early, and has suffered since.  She saw a PT for quite a long time, but found that she was worse after these sessions so has stopped.  I have seen her 4 times.  I am only doing half hour sessions with her as she tires quickly. I have been working with her to not overdo her lift and contraction of pelvic floor and TA.  Initially, at times, 20% would cause pull in the area, so we dropped it back to 10%.  Now that shearing/pull doesn’t hit until 30-40%, so we are working at about the 20%.  I have been doing supine, sitting, sidelying and today some standing work with her.
 
Supine – very small lateral leg openings with flex band behind leg, also medial leg mvmts, foot on toning ball, scap isolations, light adductor with mini ball, focus on left/right side pc
Side lying – small ext hip rotation, scap isolations
Sitting – I have some gliding discs – on raised mat, small sgl leg presses, then dbl leg presses and today small alt/reciprocal mvts, arm raises and today small swimming arm mvts (at chest height)
Standing – Cadillac push through bar – sgl lat pull and dbl then with roll down bar(small mvmt just until she felt core connection
 
She saw a specialist at the hospital this week who has suggested surgery.  She is not keen to undertake this option and was disappointed they offered her nothing else.  Am I heading in the right direction with Rachel?  What else should I do.
 
My other client with TMJ is currently off on school hols so I will let you know how we get on in a few weeks.
 
Thank you so much
Sonia, Progressive Pilates, New Zealand

Response from Melanie Byford-Young:

Hi sonia!
Great question. Osteiitis pubis can be very debilitating and hard to figure out. You are doing good exercises already.
Essentially you have to imagine that the pubic symphysis can get pulled apart very easily, even just via the contraction of the hip adductors. Your goal is to try to work the myofascial slings to hold her together- the anterior and posterior slings. You need to get the external control adn the internal control of the local stabilizers.
There are several other things you can try
1) breathing- see if she can tolerate breathing like she is sucking in through a straw, and gently lifts the pelvic floor as she does (i.e. uses the breathe to lift the pelvic floor) instead of focusing on contracting the pelvic floor (PF) muscles specifically. It can be a more gentle way and uses the diaphragm with the PF. If she can, use this technique then have her hold the PF up while she exhales. If this works, repeat hourly through the day.
2) swimming prep on hands and knees to get the posterior oblique sling supporting the pelvis and spine
3) footwork on teh reformer- probably 2 springs starting with the stopper out at position 6. Progress range first then weight and rhythm. Running can be very effective at beginning to tolerate weight shifting. Then, progress to shifting weight from on leg to the other.
4) sleeper on the reformer/ V2Max with the  spring from above (flexband supporting the leg)
5) standing arm work on the rotational discs, bosu or just on the floor. Light to moderate weight, bilateral first then unilateral. Eventually you want to do it standing on one leg.
6) sitting on a stability ball and doing imprint  and release, arm circles, spine twist etc. Vary her leg positions as able.
That should keep you busy.
Let us know how it goes!
Melanie

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

Singing and Pilates

Darcy said Pilates breathing and singing breathing is the same except for some funneling of the ribs. So there is some rib stuff, but otherwise it’s the same. Darcy Dillon teaches the Thomas Blaylock Method and it’s made a huge difference for my voice, but it also made it easier for me to understand Pilates breathing.

See a pelvic rotation? Check out the tensor fascia latae.

Hello all!

I have made an interesting discovery lately with two of my students. I thought others might have had similar experiences, and I would love to hear more about what you think!

I work with one gal that has a clockwise pelvic rotation. She has a history of left knee pain and burning along the peroneal nerve on the same side. In addition, her left femur is medially rotated. She believes that some or all of this may be attributed to a ski accident over 20 years ago.

At any rate, over the last month, we (she and I) have made an interesting discovery. It seems that most of the rotation and pain in that leg is due to the fact that she constantly grips her left TFL (tensor fascia latae) and possibly iliacus.

So, we discovered that whilst pushing out in from the bar in footwork she grips in her hip (thus medially rotating her hip and causing the clockwise rotation) instead of using her adductors or quadriceps on that leg. It is really interesting. Even when lying supine with her knees bent and a fitness circle or ball between her knees, she uses these muscles instead of her adductors! As soon as she stops doing it, her pelvis looks symmetrical.

Then, I realized that I had another student that was doing the same thing, and believe it or not, the same results occured. It is really exciting.

I would love to hear if anyone else has had a similar experience.

Leslie

Osteoporosis & Pilates

This question was sent and responded to through email, but we thought others might be interested!

Hi Pacific Northwest,
This is Christi Tuck from the YMCA in Colorado Springs. I thought I would run this question by your studio since over the years we have had your instructors come out to the Springs to do our CEC’s. Anyways, I have a client that was recently diagnosed with osteoporosis of the spine and osteopenia of the hip. I have done quite a bit of research regarding safe exercises for her, however I am still not sure about backward flexion, e.g. backrowing roll-down on the reformer … I know to avoid all forward flexion and lateral flexion. Her doctor said minimal spinal rotation with no resistance would be okay. Any thoughts on the backward flexion??
Thanks for any information you can provide. Have a great holiday weekend.

Sincerely,

Christi Tuck

Answer from Leslie Braverman:

Hi Christi:

This is a great question!

The conservative approach is to omit all flexion and rotation from a client’s workout. Unfortunately, most normal people have to conduct some flexion and rotation in their daily lives, so, in my opinion, it is a good idea that they know how to do these movements appropriately and without alot of loaded compression. Practically speaking, an individual will have to do these movements but should be educated to know what is appropriate for the overall health of their bones.

The thing I try to do is to make sure that the flexion and rotation is never in a loaded position and is done minimally during a workout (i.e. with lots of exercises that include extension and neutral spine spaced between.) Loaded flexion includes ANY inverted work. I would make certain never to do any roll over, short spine type of exercises. Especially because the thoracic spine can fracture easily, you want to make very sure that you omit these kinds of exercises—easily done. This is, of course, something to keep in mind when working in a group setting, also, when you don’t know all the students or their history very well.

In addition, you may need to be cautious with other types of loaded rotation or flexion that uses alot of spring tension or sends a great amount of loaded compression through the spine (I would be careful with things like stomach massage and elephant in a round back position). Also, exercises that combine flexion and rotation in one should, generally, be omitted (i.e. saw, stomach massage with twist etc.)

Do your best to keep your client working in neutral positions as much as possible. As an important aside, loading the bones in other ways would be great and makes Pilates a safe and effective tool for bone building! (i.e. footwork, jumping on the STOTT PILATES® jumpboard, armwork with the spine in a neutral position) all of these types of exercises are going to help your client to build bone without stressing one particular area of the spine too much. Good for you…. being a smart and inquisitive instructor!

I also hope that Melanie and Jean will put in their two (or three) cents!

I hope you are well…all my best to everyone in Colorado Springs.

Leslie

Reply from Christi:

Hi Leslie,
Thank you so much for your quick reply. Your information was invaluable and it also helped confirm the changes I have made to her workout. We had a private session on Friday with omitting the exercises you have mentioned with a main focus on staying neutral. She attended my reformer class yesterday so I was able to ask her how her body responded with the changes we made and I am pleased to say she felt great. Fortunately, she has been doing pilates for a while so her mind/body focus is wonderful. I am happy to hear that you think the jumpboard is a good option because she enjoys it. Thanks again for all your information.

Sincerely,

Christi Tuck

Flat abs without back pain

This question was sent and responded to through email, but we thought others might be interested!

Melanie:

What are some good ab exercises that I can do without hurting my back? Do you have research to support these ideas?

Hello,

The most beneficial way to strengthen your abs, flatten your stomach and not hurt your back is to do abdominal exercises that encourage proper recruitment of the spinal and pelvis stabilizing muscles: the pelvic floor and transversus abdominis muscles. To do this, you need to understand how to “recruit” these muscles (in lieu of using other muscles, which is common) and how to tell if they are staying “on” (instead of using those other muscles) while you complete abdominal exercises.
The transversus abdominis is the deepest layer of abdominals. It does not, by design, create movement. Instead, it creates stability for the spine and flattens the abdominals. It is important to make sure that while exercising the transversus abdominis, it is pulling in and flattening sideways (the fibers run horizontally around the trunk like a corset).
These muscles work best when the pelvis and lumbar spine are placed with the natural curve in the lumbar spine (i.e. when the back is not flattened into the mat) and the back muscles are not gripping.

There are several basic exercises one can practice to find the pelvic floor muscles. Since the pelvic floor muscles attach to the underneath side of the pelvis (these are the same muscles that control urination) they are felt easiest by sitting on a ball and gently bouncing up and down or by folding up a small wash cloth and sitting on it. These devices give some feedback for the individual.

To strengthen these muscles, gently connect these muscles by thinking of lifting them upward slightly. (It should feel like the same muscles that work to keep you from urninating.) It is important to be able to gently lift them for a count of 5, hold them on for a count of 5 and release them for a count of 5. They should not be working at 100% but closer to a 25% level.

Transversus should become active just prior to incorporating other muscles. When the transversus abdominis is recruited properly, you see a flattening or drawing in of the lower abdomen without any noticeable movement of the spine or hips.
To get the look of a flat, strong abdomen, you need a variety of different exercises in your routine. Some include:
1) Challenging the spine in neutral (plank, head and shoulders on the ground) ensuring the spine remains as it starts throughout the exercise
a. Toe taps
b. Dead bug series
c. Scissors with head down
d. One leg circle
e. Push ups
f. Leg pull front
2) Flexion routine- ensure that lower abdominals are set prior to and throughout the motion
a. Roll up
b. Obliques with single leg stretch
3) Extension based exercises- keep abdominals lifting up
a. Swan dive
b. Swimming
More info about the transversus abdominis:
1) acts as a corset, drawing in circumferentially as it protects the spine
2) stabilizer of the lumbar spine by virtue of:
- insertion into the thoraco-lumbar fascia, which inserts into the vertebrae,
- its neurological firing pattern (fires before movement begins so that the spine is protected and prepared
- coordinated work with the other stabilizers including the pelvic floor muscles, diaphragm, deep psoas, and multifidus
3) creates motion around the proper axis of motion, and prevents unwanted shearing or translation of the vertebra which can lead to irritation and degeneration of the discs and facet joints
4) provides compression (in a good way) so that the larger muscles have a stable base to pull from
REFERENCES:
1. Lee, Diane: The pelvic Girdle, Third Ed. Edinburgh, Churchill Livingstone, 2004
2. Richardson C, Hodges P, Hides J: Therapeutic Exercise For Lumbopelvic Stabilization: Motor Control Approach to the Treatment and Prevention of Low Back Pain, 2nd edition, Edinburgh, Churchill Livingstone, 2004
3. Vleeming A et al: Movement, Stability and Low Back Pain- The Essential Role of the Pelvis 2nd edition, at press, 2006
Articles
3. Lee, Diane (1998) Stress Urinary Incontinence: A consequence of Failed Load Transfer Through the Pelvis? Proceedings from the Third Interdisciplinary World Congress on low Back and Pelvic Pain. Vienna, Austria www.dianelee.ca <http://www.dianelee.ca>
4. Lee, Diane (2005) Recent Advances in the Assessment and Treatment of the Sacroiliac Joint- Stability & the Role of Motor Control. www.dianelee.ca <http://www.dianelee.ca>
5. Richardson C A, Snijders C J, Hides J A, Pas M S (2002) The Relationship between the Transversely Oriented Abdominal Muscles, SIJ Mechanics and Low Back Pain. Spine 27(4): 399-405
7. Vleeming,A Stoeckart, R, Volkers A C W, Snijders CJ (1990a) Relation between Form and Function in the Sacroiliac Joint, 1: Clinical Anatomical Aspects. Spine 15(2): 130-132
8. Vleeming,A Stoeckart, R, Volkers A C W, Snijders CJ (1990b) Relation between Form and Function in the Sacroiliac Joint, 2:Biomechanical Aspects. Spine 15(2): 133-136

Scoliosis and scapula

My name is Brigitte and I’m a certified STOTT PILATES instructor and massage therapist in Montreal. I have watched you over many hours while editing the rehab DVD series that you did (I edit from English to French). I find you very knowledgeable, inspiring and motivating and if I could, would love to just spend a few months with you to learn even more (something that right now is not possible but who knows what the future holds!). I’m writing to you because I’d like to have your opinion on someone I’m working with. I realize that you cannot make any diagnosis or give me the absolute answer regarding this client, however perhaps you could shed some light.

I’ve been working with a woman for over a year now, she has spondilolithesis (so she’s obviously quite kyphotic in thoracic and hyperextended in cervical), fused lumbar, with a slight scoliosis, winging right scapula. She has a lot less stability in right shoulder and scapula. I have been focusing on spinal extension and scapular stabilization. I also work her in seated, kneeling and standing positions to encourage recruitment of the spinal and pelvic stabilizers in a neutral position. My one issue that I have is this terribly winging right scapula. I make her do lots of rotator cuff work, I also do lots of protractions against resistance to work her serratus anterior. I work on the cadillac, doing mid, lower and upper trap work, often unilaterally. The upper fibers of her rhomboids and mid traps seem to be firing well. However her mid to lower area of her scapula is always winging at a certain degree, usually when her elbows are bent (ex: when they’re bent and at elbow height, or while side-lying and doing ext. rotations with ball – although this has improved greatly). I make her do certain things and think, wow, her scapula is flush and moving smoothly. Then I make her do something else and it totally pops right off. I’ve been trying to help by placing her against a wall, with elbows bent at 90 degrees, in line with her shoulders. I then get her to do external rotations, bringing her forearms to the wall. She has a much smaller range with her right side and sometimes cringes while attempting this (she has improved but still not to full range).

Is there anything else I could do, it’s just boggling my mind and I really want to help this woman. I know I already have but I’m stumped. I started to think that she has quite a few active trigger points which may be preventing her from getting that full range. Either way, anything insight you could give would be much appreciated. I hope to one day attend one of your workshops, perhaps when you’re a little closer to Montreal!

Thanks so much and have a great day!

Sincerely,
Brigitte

From Brigitte to Pacific NW Pilates