Pilates for the Management of Knee Joint Hypermobility

Natalie Nyikadzino

12 June 2019

Ballito

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ABSTRACT

The knee joint is a synovial hinge joint, consisting of the tibiofemoral and patellofemoral

articulations. It controls the centre of gravity and transmits forces along the kinetic chain

to perform functional movements (Nordin & Frankel, 2012). Movement occurs primarily

around the tibiofemoral joint in the sagittal plane. Ligaments play a major stabilizing

role, preventing excessive range of movement of two articulating bones in relation to

another (Hall, 2015). They are composed primarily of collagen and elastin, giving them

the capacity to sustain large tensile loads (Nordin & Frankel, 2012). They will return to

their original length after being stretched, unless stretched beyond their elastic limits.

When the ultimate tensile strength of these structures is exceeded, complete failure

occurs and their load-bearing ability decreases significantly (Hall, 2015)

Hypermobility is defined as an excessive range of joint motion as a result of

ligamentous laxity, which is mostly hereditary (Beighton, Grahame, & Bird, 2012).

Abnormal loading of the joint surfaces of the knee can accelerate degenerative changes

and this is directly proportional to the degree of joint laxity (Beighton, Grahame, & Bird,

2012). The hamstrings and quadriceps co-contract assist the ligaments to stabilize the

knee joint (Nordin & Frankel, 2012).

Using the BASI Block System, a 12-week program was designed to improve the

dynamic muscle stabilization around the knee joint of a 26-year old female, diagnosed

with genu recurvatum and chondromalacia patella.

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TABLE OF CONTENTS

ABSTRACT .................................................................................................................................................... 2

ANATOMICALDESCRIPTION ........................................................................................................................ 4

BACKGROUND ............................................................................................................................................. 7

PropertiesofConnectiveTissue .............................................................................................................. 7

Hypermobility .......................................................................................................................................... 7

LoadsontheKneeJoint........................................................................................................................... 8

Co-contractionoftheKneeStabilizers .................................................................................................... 9

CASESTUDY ................................................................................................................................................. 9

SummaryofProgressions ...................................................................................................................... 12

Conclusion ............................................................................................................................................. 13

BIBLIOGRAPHY........................................................................................................................................... 14

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ANATOMICAL DESCRIPTION

The knee joint is a synovial hinge joint, consisting of the tibiofemoral and patellofemoral

articulations. Movement occurs primarily around the tibiofemoral joint in the sagittal

plane. The knee joint controls the centre of gravity and transmits forces along the kinetic

chain to perform functional movements (Nordin & Frankel, 2012). Situated between two

of the body’s longest bones, the femur and the tibia, the knee withstands large

compressive forces and shear forces during weight bearing. The main structures that

reduce impact between the femoral condyles and tibial plateau are the medial and

lateral menisci and articular cartilage (Figure 1). The normal range of motion of the knee

ranges between small degree of hyperextension -3º to full flexion at approximately 155º

(Nordin & Frankel, 2012).

Figure 1: Anatomy of the bones and connective tissue of the tibiofemoral joint

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Ligaments play a major stabilizing role, preventing excessive range of movement of two

articulating bones in relation to another (Hall, 2015). The anterior cruciate ligament

(ACL) and the posterior cruciate ligament (PCL) resist anterior and posterior tibial

translation respectively. The medial collateral ligament (MCL) and lateral collateral

ligament (LCL) resist valgus and varus forces respectively (Hall, 2015).

Joint stability is also achieved passively via the screw-home mechanism, where the tibia

rotates laterally in relation to the femur to maintain full extension, but simultaneously

preventing hyperextension. All ligaments are taut in this position (Nordin & Frankel,

2012).

The hamstrings and quadriceps muscle groups are the primary movers and stabilizers

of the knee joint (Hall, 2015). The hamstringsbi-articular muscles, acting as both knee

flexors and hip extensors. Due to their lines of action, the semimembranosus and

semitendinosus also perform medial tibial rotation while the biceps femoris performs

lateral tibial rotation. The rectus femoris is also bi-articular, performing both knee

extension and hip flexion (Hall, 2015). The vastus intermedius lies directly below this

and is purely a knee extensor. The vastus medialis plays a stabilizing role by opposing

the vastus lateralis, to prevent the patella from tracking laterally.

Deep to the hamstrings is the popliteus muscle that responsible for unlocking the joint

from full extension, by rotating the tibia medially prior to knee flexion (Hall, 2015). Other

muscles with primary actions at the hip and ankle joints cross the knee joint as well and

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can assist with movements of the knee. The sartorius, gracilis, gastrocnemius and

plantaris muscles assist with knee flexion (Hall, 2015).

Figure 2: Anatomy of the knee joint muscles

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BACKGROUND

Properties of Connective Tissue

Tendons attach individual muscles to bone and ligaments connect two articulating

bones. They are composed primarily of collagen and elastin, giving them the capacity to

sustain large tensile loads and allow for some level of deformation (Nordin & Frankel,

2012). They will return to their original length after being stretched, unless stretched

beyond their elastic limits. When the ultimate tensile strength of these structures is

exceeded, complete failure occurs and their load-bearing ability decreases significantly

(Hall, 2015). In joints like the knee that are designed for greater mobility, the tension in

ligaments and muscles contributes significantly to joint stability (Nordin & Frankel,

2012). Tendons and ligaments also provide proprioceptive feedback through their

neural structures, which is essential for motor control (Nordin & Frankel, 2012).

Hypermobility

Hypermobility is defined as an excessive range of joint motion as a result of

ligamentous laxity, which is mostly hereditary (Beighton, Grahame, & Bird, 2012). It can

be present in one joint or multiple joints, and is usually asymptomatic. Abnormal loading

of the joint surfaces of the knee can accelerate degenerative changes and this is

directly proportional to the degree of joint laxity (Beighton, Grahame, & Bird, 2012). As a

result, hypermobile individuals who engage in demanding, high impact physical

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activities are most susceptible to injury (Beighton, Grahame, & Bird, 2012). Genu

recurvatum is the hyperextensibility of the knee joint specifically, which likely

predisposes individuals to degenerative conditions like chondromalacia patella, the

damage to articular cartilage on the posterior surface of the patella (Beighton, Grahame,

& Bird, 2012). It is commonly seen among physically active adolescents and young

adults. Individuals with genu recurvatum have poor joint proprioception at the end-

range, therefore it is important to train their postural awareness and muscle control.

Figure 3: Coronal view of genu recurvatum relative to neutral knee joint alignment

Loads on the Knee Joint

During the gait cycle, the stance limb must support the weight of the entire body. The

knee joint itself withstands compressive forces exceeding three times an individual’s

body weight during the stance phase (Hall, 2015). The alignment of the knee is also

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influenced by the alignment of the hip proximally, and of the ankle and foot distally. This

determines how efficiently forces are transmitted along the kinetic chain to perform the

desired movement (Oatis, 2009). Since the knee forms one link in the kinetic chain, it is

necessary to address the stabilizing muscles around the trunk, hip and ankle joint as

well.

Co-contraction of the Knee Stabilizers

The angle of attachment of most tendons to bones is arranged so that when the muscle

contracts, the articulating ends of the bones are drawn closer together, enhancing joint

stability (Hall, 2015). This is the result of agonist and antagonist muscles contracting

simultaneously. Many functional movements recruit the muscles in co-contraction, like

walking, running, bending and lifting. The hamstrings and quadriceps co-contract to

stabilize the knee and assist the ligaments (Nordin & Frankel, 2012). When muscles are

fatigued or imbalanced in strength, they are less capable of performing this stabilizing

role, increasing the risk of injury. The ideal ratio of hamstring strength to quadriceps

strength according to literature is approximately 0.45 to 0.65 (Oatis, 2009).

CASE STUDY

Amy is a 26-year old female who has been generally active her entire life. She has

participated in various sports including swimming, hockey, rowing and road running.

She has experienced several episodes of knee pain but they would eventually subside.

It was common for her knees to click when moving from flexion into extension but this

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was not painful. Three years ago, the episodes occurred more frequently and were

more painful, lasting for longer periods. She consulted an orthopedic surgeon who

noted her hyperextended knee position and an MRI revealed that she had

chondromalacia patella in both knees. Although she was generally active, she had

muscle strength imbalances, especially the hamstrings, vastus medialis and gluteal

muscles. As a result, she did not have sufficient dynamic joint stabilization to protect the

other structures in the knee joint while performing high-impact sports. Since Amy would

like to participate in similar activities throughout her life, it is important that the muscle

imbalances are addressed with a program tailored to her imbalances.

The BASI Block System categorizes each exercise in the Pilates repertoire according to

different body regions. It provides a systematic way to address the body as a whole,

while being selective about the muscle focus and movement objectives of each exercise

(Isacowitz, 2014). As clients achieve the objectives with greater ease and control, the

instructor can progress the exercise complexity by selecting the appropriate substitute

while maintaining the muscle focus and objectives. This enables the instructor to design

and adapt an exercise program for a specific client’s capability. This process describes

the overload principle, where damage to muscle tissue is induced deliberately by

loading it above its yield threshold (McGinnis, 2013). This will initiate the tissue

remodeling process to increase the muscle’s capacity to tolerate greater training loads.

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Using the BASI Block System I designed a 12-week program with two sessions each

week. Progressions were made after every fourth week, as outlined in Table 1. The

asterisks highlight exercises specific to addressing knee joint stabilization. These are

discussed below.

Table 1: Comprehensive 12-week program for management of knee hypermobility

BLOCK Week 1-4 Week 5-8 Week 9-12 Warm up Mat Basic

Pelvic curl* Spine twist supine Chest lift Chest lift with rotation

Mat Intermediate Roll up Spine twist supine Double leg stretch Single leg stretch Criss cross

Avalon Roll up Roll up with extension Mini roll up Mini roll up oblique Spine twist supine

Foot work Reformer Foot work series*

Cadillac Foot work series*

Wunda chair Foot work series*

Abdominal work Reformer Hundreds prep Co-ordination

Wunda chair Cat stretch kneeling Pike sitting

Wunda chair Full pike

Hip Work Reformer Frog* Down circles Up circles Openings

Cadillac Double leg supine series: Frog* Down circles Up circles Walking Bicycle* Bicycle reverse*

Cadillac Single leg supine series: Frog* Down circles Up circles Hip extension Bicycle* Bicycle reverse*

Spinal articulation

Reformer Bottom lift* Bottom lift with extensions*

Reformer Short spine Long spine

Stretches Ladder barrel Gluteal Hamstrings* Adductors* Hip flexors*

Reformer Kneeling lunge*

Reformer Full lunge*

Full body integration (F/I)

Reformer Scooter Up stretch 1

Reformer Up stretch 2 Long stretch

Arm work

Wunda chair Shrugs Triceps press sit

Reformer Sitting series Chest expansion Biceps

Cadillac Chest expansion Hug-a-tree Up circles

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Rhomboids Hug-a-tree Salute

Down circles Punches Biceps

Leg work Wunda chair Hamstring curl* Hip opener

Reformer Hamstring curl* Cadillac Squats*

Wunda chair Backward step down* Forward lunge*

Lateral flexion/Rotation

Reformer Mermaid

Wunda chair Side stretch

Reformer Side over on box

Back Extension Reformer Breastroke prep Pulling straps 1

Wunda chair Swan basic Swan on floor

Reformer Breastroke Pulling straps 2

Discussion of Key Exercise Progressions

Warm up: The Pelvic Curl on the mat is the first exercise where the co-contraction

between abdominals and hamstrings is taught.

Foot work: The client is instructed to initiate the movement by engaging the

hamstrings. Co-contraction of quadriceps and hamstrings is encouraged at end-range to

avoid hyperextension. The seated position with no trunk support on the Wunda chair

requires greater postural awareness and trunk stabilization.

Hip work: From bilateral hip work with equal distribution of spring tension on reformer

straps, to unilateral hip work with individually loaded springs on Cadillac. Requires

greater pelvic stabilization, hip extensor control and hip disassociation. The Frog trains

the hamstrings and quadriceps co-contraction to maintain stability around the knee joint.

The Bicycle engages the hamstrings in their other role as a knee flexor.

Spinal articulation: During the Bottom Lift, there is increased load on hamstrings and

co-contraction with abdominals to keep the carriage stationery as the spine articulates.

The hamstrings are then required to maintain hip extension and perform knee flexion for

the Bottom Lift with Extension.

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Stretches: From static stretches on ladder barrel to dynamic stretch on moving reformer

carriage, requiring greater control and awareness of pelvic position. When they are

tight, the hip flexors oppose the role of the hamstrings, resulting in an anterior pelvic tilt.

Therefore, both muscle groups are stretched to avoid this.

Leg work: From bilateral leg work in supine position, to unilateral leg work in standing

position. Greater hip extensor strength and abductor control required to maintain the

correct alignment of the entire kinetic chain. Hamstrings and quadriceps are working in

co-contraction.

Conclusion

The Pilates method is an appropriate form of exercise to manage knee joint

hypermobility as there is a stabilizing component to each exercise prior to initiating

movement. The stabilizers remain engaged throughout the exercise, which enhances

their capacity to support the joint for prolonged periods. This has been shown to

significantly reduce joint pain in symptomatic individuals in other studies. Also, the

opposing muscle groups are often recruited in a co-contraction to support the joint

throughout its range of motion. Integrating the key principles of awareness and control

in the cues provided facilitate the mind-body connection and make the individual more

conscious of their joint positioning, both statically and dynamically.

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BIBLIOGRAPHY

Anon., 2013. Healing Healthy Holistic. [Online] Available at: http://healinghealthyholistic.com/wp-content/uploads/2013/11/leg-muscles-1024x782.jpg [Accessed 12 May 2019].

Anon., 2015. [Online] Available at: http://boneandspine.com/wp-content/uploads/2015/09/upper-tibia-diagragm1.png

Anon., 2015. Bone and spine. [Online] Available at: http://boneandspine.com/wp-content/uploads/2015/09/upper-tibia-diagragm1.png [Accessed 12 May 2019].

Anon., 2015. Science of massage. [Online] Available at: https://www.scienceofmassage.com/wp-content/uploads/2015/07/GENU1-680x332.png [Accessed 12 May 2019].

Beighton, P., Grahame, R., & Bird, H. (2012). Hypermobility of joints. (4th, Ed.) London: Springer.

Hall, S. (2015). Basic biomechanics (7 ed.). Delaware: McGraw-Hill, .

Isacowitz, R. (2014). Pilates (2nd ed.). Illinois: Human Kinetics.

McGinnis, P. (2013). Biomechanics of sport and exercise (3rrd ed.). Illinois: Human Kinetics.

Nordin, M., & Frankel, V. (2012). Basic biomechanics of the musculoskeletal system. (4th, Ed.) Baltimore: Lippincott Williams and Watkins.

Oatis, C. (2009). Kinesiology: the mechanics and pathomecanics of human movement (2nd ed.). Baltimore: Lippincott Williams & Wilkins.