by Jean Leavenworth on February 1, 2010
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.
by Leslie Braverman on October 11, 2009
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
by Leslie Braverman on October 9, 2009
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
by Melanie Byford-Young on July 28, 2009
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
