Introduction and Goals for Pilates for Hip and Knee Syndromes and Arthroplasties – Page xx
Pilates for Hip and Knee Syndromes and Arthroplasties covers the mat work as it relates to the Pilates method. This manual addresses how the mat work can be modified for hip and knee syndromes as well as for pre- and postoperative rehabilitation of clients with hip or knee replacements, formally known as arthroplasties. It is the intent of this book to show the adaptability of the method as a key form of fitness and rehabilitation for these populations, especially during the first post- operative year.
The goals of this book are to (1) further introduce Pilates to the orthopaedic community as a safe and efficacious form of fitness and rehabilitation to restore function, strength, and balance to the motivated client with a knee or hip syndrome or arthroplasty and (2) help qualified Pilates instructors feel comfortable working with a client with a knee or hip syndrome or arthroplasty by setting up protocols with specific modifications for these populations. Basic modifications are taught during the training program; however, not enough information is covered in most programs to help the instructor feel comfortable working with a client with a joint syndrome or replacement.
When working with a client with a syndrome, it is important to select a program that allows the individual to work successfully within a range of motion without pain. When working with a client with a recent joint replacement, it becomes extremely important to build a foundation upon which the client can over time return to a safe range of motion with full function. Working effectively, building core strength, and staying within safe parameters allow for a gradual return to normal life activities and sports.
The guidelines for movements performed on each piece of Pilates equipment are covered in the web based resource chapter that is accessed by a key code with the book. The movements that are listed with suggested ROM guidelines in the chapter come from Joseph Pilates original work. Pilates for Hip and Knee Syndromes and Arthroplasties bridges the worlds of the physician, physical therapist, and Pilates instructor by laying down the foundation and guidelines for comfortably working with a client with a knee or hip syndrome or joint replacement based on current technology and findings.
Hip Osteoarthritis – Page 8, chapter 1
Osteoarthritis of the hip is a very common disorder. It is estimated that 185,000 THAs were performed in 2002 for degenerative hip conditions (Kurtz et al. 2005). It is also estimated that 43 million Americans have osteoarthritis. There is a linear association with advancing age. Diagnosis is made on a clinical history of groin pain, difficulty with rotational activities of the hip (such as putting on socks and shoes and getting in and out of a car), and pain related to activity. Physical examination often demonstrates groin pain with attempted hip rotation as well as significantly restricted rotational motion of the hip; limited internal rotation and external rotation contracture are most common. A flexion contracture of the hip is not uncommon and is associated with contracted anterior hip structures, including the hip capsule and hip flexors. Excessive hip contracture can lead to increased stress on the lumbar spine that is often compensated by an exaggerated lumbar lordosis.
Often, plain radiographs are all that is necessary to diagnosis hip osteoarthritis, as joint space narrowing, osteophyte formation, subchondral sclerosis, and cyst formation can be readily seen on plain X rays. More advanced imaging studies typically are not necessary to establish the correct diagnosis. Nonoperative treatment modalities include oral or topical anti-inflammatory agents, weight loss, use of assistive devices, and low-impact stretching and strengthening exercises. A more rigorous exercise program usually is not well tolerated in patients with osteoarthritis. The sample Pilates sequence in chapter 7 (see p. 339) involves a series of low-impact stretching exercises that may be helpful in maintaining well-being and fitness as well as ROM at the hip joint. As the pain progresses and the ROM decreases with advancing osteoarthritis, the Pilates exercises should be modified to accommodate these limitations while still maintaining a healthy lifestyle. When the pain interferes with activities of daily living, disrupts sleep patterns, or becomes incapacitating, the patient should seek physician care.
Patellofemoral Syndrome and Chondromalacia of the Patella – Page 19, chapter 2
Patellofemoral pain syndrome encompasses a broad class of syndromes that are characterized by significant and diffuse anterior knee pain (surrounding the patella) and that are exacerbated by activities placing undue stress on the anterior compartment of the knee (such as running, navigating stairs, kneeling, squatting, and rising from a seated position). During these high-stress activities, the forces across the patella can range from 3 to 8 times a person’s body weight. While patellofemoral syndrome encompasses the entire constellation of syndromes associated with the anterior compartment of the knee, chondromalacia of the patella describes the softened surface of the articular cartilage of the patella and is a pathological change to the cartilage rather than a condition. Specific numbers are difficult to establish; however, patellofemoral knee pain is responsible for a significant percentage of office visits each year to orthopaedists and general practitioners.
Clinical symptoms include pain around the kneecap that worsens with rising from a seated position, climbing stairs, running, and jumping. There may be a history of patellar dislocation, feelings of knee instability, or a sensation of internal catching. Typically, a specific traumatic event is not identified, but on occasion a direct blow to the patella can be the initiating source of pain. On physical examination, patients often have a genu valgum (knock-knee) deformity, walk with the patellas pointing toward one another (increased femoral anteversion or pigeon-toe gait), and demonstrate crepitation as they flex and extend the knee. The Q angle is formed by the intersection of a line drawn from the anterior superior iliac spine (ASIS) through the middle of the patella with a second line drawn from the tibial tubercle to the middle of the patella. Often this angle is increased in patients with patellofemoral pain and can be associated with patellar instability, chondromalacia of the patella, and patellofemoral arthrosis. When the knee is in extension, the Q angle should be less than 18° and 22° for men and women, respectively.
Conservative management of patellofemoral pain is the treatment of choice and is based on the underlying etiology of the syndrome. The goal is to develop a program to strengthen the quadriceps, particularly the vastus medialis muscle, to assist in proper tracking of the patella. Patella taping and patella sleeve braces may also offer pain relief and comfort. Use of the Pilates method in treating patellofemoral pain has not been documented at this time.
Listed in this manual is a series of exercises that can be used to strengthen and stretch the anterior structures of the knee and possibly treat patellofemoral syndrome. The exercises discussed are similar to those initiated in a formal physical therapy regimen and serve as an alternative option to attending traditional therapy. The sample Pilates program sequence outlined for pes anserinus bursitis can be followed and adapted to treat anterior knee pain. The goal is to start with a pre-Pilates program to work on strengthening the core and establish an appropriate warm-up regimen to include stretching and breathing. Once the core-stabilizing exercises have been completed, the regimen can be modified to focus on stretching the hamstrings and quadriceps using the prone leg lift, single-leg circle, half roll-down into full roll-up, modified shoulder bridge, spine stretch forward, and saw. Quadriceps strengthening can be achieved with the sitting bent-knee lift, quadriceps set, modified leg pull-up, modified hip circle, and a side kick series (SKS) consisting of up and down, front and back, small circles, D-circles, and bicycle. It is recommended to use topical or oral anti-inflammatory agents and local massage to aid in the resolution of patellofemoral pain. Typically, anterior knee pain responds to 4 to 6 weeks of targeted therapy. When the pain persists beyond this time interval, the patient should seek further treatment with a physician. People prone to patellofemoral pain should incorporate this Pilates series into their weekly workout regimen.