SHIFTING PAT TERNS/RELIEVING PAIN THROUGH PILATES

A Student Paper for BASI Pilates

Pilates Case Study! 1

Todd TaylorDecember 1, 2014Class of Fall 2008

Mill Valley California

AbstractThe human body works to achieve balance. If a structure in the musculoskeletal system is compromised or injured other body parts are going to compensate to find equilibrium, espe-cially if the injury or structure in question is at a weight bearing joint. Imagine a “domino effect” where the injury is a torn medial meniscus eventually resulting in chronic back pain. Over time a cascade of symptoms develops from “pain avoidance.” One’s gate when walking might be modified to avoid pain in the medial portion of the knee. Other resulting symp-toms might include a tight hip, a sore shoulder or both for example. The nagging discomfort of a sore back, an area distant from the initial injury, drives a person to seek relief. The treatment may come in the form of physical therapy or more invasive procedures. Often left un-addressed are the patterns that have developed throughout the body from the initial injury and the postural habits of daily life. A BASI Pilates program can restore balance and unwind those patterns in the body, relieving painful symptoms.

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TABLE OF CONTENTS

1. Anatomical Description of affected areas...pages 4-6

2. Introduction...page 7

3. Case Study...pages 8-9

4. BASI Conditioning Program utilizing the Block System...pages 9-12

5. Conclusion...pages 12-13

6. Bibliography...page 14

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ANATOMICAL DESCRIPTION OF AFFECTED AREAS

Posterior Illiac Crest, Piriformis, Gluteus Medius, and Sciatic NerveThis is is commonly “ground zero” for pain in people who may engage in repetitive motion exercises, those who sit a lot, and those with structural anomalies such as external rotation of the femur. Other factors contributing to pain in this area may arise from a sitting or standing default posture away from a “neutral pelvis position” that presents itself as either an anterior or posterior tilt to the pelvis. Compression in the low spine/sacral junctions and at the sacroilliac joint can can create pain or discomfort and effect ambulation. Beyond the skeletal structures there is often compression in the soft tissue structures of the hip which may include the gluteus medius, piriformis, quadratus lumborum, and external oblique mus-cles.

Pain and inflammation will often present itself in the gluteal region including gluteus medius and piriformis which can, depending on the person put pressure on the sciatic nerve. If there is enough muscular inflammation, compression, or lack of relative movement between structures pressure on the sciatic nerve can refer pain down the leg. Superior to the illial crest are deep and superficial muscles found in areas complained about by low back pain suf-ferers who sit often.

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Posterior attachment of external obliques at illiac crest

Quadratus Lumborum attachments at illiac crest

Tibial PlateauPictured to the right is the surgical repair of a fracture to the tibial plateau of the medial right knee. The tibial pla-teau is the most weight bearing surface in the body. Pain this region could cause changes in standing and walking be an initial trigger for other maladies in the muscles and bones above and below the knee.

Postural Deviations of the Spine and PelvisSkeletal extremes beyond a desired anatomical postural position can create painful symp-toms that present themselves in the neuromuscular and myo-fascial systems of the body.

In the example below right, the head is forward of the anatomical plumb line, creating com-pression in the cervical spine leading to tightness and soreness of cervical extensor and up-per trapezius muscles. An exaggeration of the kyphotic curve of the thoracic spine can cre-ate a chronic “fatigue” state in the muscles of the mid and upper back, and often translates into an inability to articulate from one vertibra to the next and an immobility of the muscu-

lature relative to those skeletal structures. Tho-racic kyphosis often translates to a hyper lordotic curvature of the lumber spine combined with an anterior pelvic tilt. This contributes to com-pression and pain in the musculature of the upper posterior hip and low back as well as a shortening of the hip flexors. Weak abdominal muscles, par-ticularly rectus abdominus, and transversus ab-dominus will be found in combination with this postural phenomenon.

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External Rotation of the Femur

In this photo the right femur is in external rotation. This anatomical position, when presenting as the default in weight bearing activities such as standing, walking, or sit-ting, leads to muscular imbalance that also can contribute to low back pain and me-dial knee instability due to overused and

overdeveloped vastus lateralis and sartorius muscles as well as weak unstable adductor mus-cles. The lateral lines of the superior lower extremities (Vastus Lateralus, Illial Tibial Band, and Tensor Fascia Late) can become chronically tight. This tightness often goes hand in hand with compression and tightness of the rotators of the hip (Gluteus Medius, and Piri-formis) where low back and hip pain show up.

Structural imbalance in the upper portion of the lower extremities may also be associated with some sort of structural anomaly in the lower portion of the lower extremities such as the ankle and foot.

In the graphic below for example pronation is exhibited in the ankle on the left thus shifting the calcaneous medially and probably rotating the malleolis either medially or laterally be-yond a neutral position. If alignment in the ankle joint is off center, there will probably be either medial or lateral compression in the knee joint depending on the situation.

Pronation

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Introduction

The student for this case study, Steve, is an athletic but slightly heavy male in his late 30’s who decided to try pilates based the recommendation of pilates professional he encountered in a yoga class. He came to Pilates for relief of pain in the low back/posterior right hip area that was getting progressively worse and had started causing him discomfort while trying to sleep. The pain was a new phenomenon and concerning because he was “strong”, “flexible” and worked hard at being fit. Disc herniation had been ruled out as a cause of the pain by his doctor.

It was during the intake on his first session that revealed postural imbalances that could be contributing to the discomfort he was experiencing. These imbalances showed up as a dif-ferential between his over utilized strengths (chest, shoulders, lateral quads) and his by-passed weaknesses (spinal erectors, transversus abdominus and obliques, as well as the ad-ductors of the hip). Ankle pronation was also present. In addition, his injury history in-cluded a fractured anterior-medial tibial plateau at age 19 that was operated on. Hardware (screws) were placed in the tibia on the medial side going through to the lateral side. They were eventually removed. Seven years prior to that at age 12 Steve suffered a medial menis-cus tear in a skiing accident that ended up in surgery on the same anterior medial side of the right knee. The knee at the time of the intake wasn’t at issue as much as the low back pain but it was duly noted.

Steve’s exercise history included proficiency at cycling (Mountain and Road) with some de-gree of frequency on a weekly basis. Steve also regularly attended power yoga classes and had previously been an avid windsurfer and skier. Pain in his knee eventually required him to stop the latter two activities. At the point of our first meeting however most of Steve’s athletic endeavors were being hampered by his low back/hip discomfort. At a basic level, Steve was having difficulty flipping from a supine to prone position in bed due to the poste-rior hip pain he was experiencing.

Steve’s current occupation required him to sit for extended periods each day either at his desk or in the car commuting which most likely was a major contributing factor to his low back/hip pain.

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A Case Study using the BASI Pilates Method

Client Complaints:

1) Pain in posterior superior (r) hip starting medially and mov-ing laterally experienced when sitting, lying, and while at-tempting to fully extend hips in certain standing postures in yoga

2) Stiffness in upper back and medial ridge of left scapula where levator scapulae and trapezius cross

3) Occasional (r) medial knee tenderness due to what he says is reduced cartilage and calcification of joint at surgical/injury site. Nothing acute, mostly chronic residual pain he has learned to live with.

4)History of shin pain when attempting to run for any length of time. Primarily felt in tibi-alis anterior and extensor digitorum longus.

Initial Postural Notes/Observations on Steve:

1) At rest, seated, and standing external hip rotation is present

2)Anterior pelvic tilt is present while standing

3) Right Hip seems slightly elevated while standing

4)Ankle pronation is evident

5) In a seated position there is a tendency to slump and the pelvis defaults to a posterior tilt

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Initial Movement Observations:

1) Slow moving in roll down while standing with limited articulation through thoracic spine

2) Signs of hip pain when returning to full, upright standing position at end of roll down.

3) Signs of discomfort in right hip when moving into supine pelvic curl during warm-up on the mat

4)Signs of strain and in-ability to create full spinal articulation through thoracic spine on way back down to neutral pelvis from supine shoulder bridge prep position.

5)Difficulty sitting erect at 90 degrees with neutral pelvis and legs extended in front. Possi-ble weakness and definite tightness in inferior erector spinae and multifidus.

6)Stiffness and lateral instability when performing side lying exercises and later torso flex-ion.

7)Massive over-use of lateral quads doing footwork on the reformer. Imbalance of weight distribution going into the small meta-tarsals during parallel metatarsal section of foot-work on the reformer. Signs of adductor weakness presented via avoidance of engagement from inner thighs through large metatarsals on same version of footwork.

A Customized BASI Program utilizing the block system:The goal in designing a comprehensive BASI Pilates program for Steve was to help him get out of low back/posterior hip pain, bring his own awareness to his postural and muscular imbalances, restore movement where he was “stuck” in his body, develop strength where there had been weakness, and help Steve hold that transformation in his body. Specific goals were to 1) improve pelvic lumbar stability 2) improve intervertebral articulation through the thoracic spine 3) increase lateral flexion and encourage opening, and pain-free movement in lateral flexion while de-compressing the area around the external oblique and Q.L. attach-ments at the illial crest 4) improve the ability to lift and extend out of a posterior pelvic tilt when seated without hands 5) increase hip adductor strength and loosen external rotators of the hip 6) strengthen muscles of the lower extremities and feet in order to eliminate prona-tion and hold a more neutral stance in the ankles and feet.

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In his initial session we covered the concepts of breath using breathing techniques in the rib cage. We began the practice of using breath to initiate muscular engagement, and then movement. We also discussed anatomical position and awareness of the boney landmarks of the feet (metatarsals) and pelvis (ASIS, Pubic Symhasis, and Sacrum) in standing , seated, and supine positions. Neutral pelvis and posterior tilt were explained. The program de-signed for Steve is below. To use the system, start at the first block then look to the right to see which apparatus is recommended for that day’s session number i.e. day 1=session 1. Ex-ercise descriptions are detailed below the table.

M A T R E-F O R M E R

C A D I L L A C C H A I R S T E P B A R-R E L

L A D D E R B A R R E L

Warm Up 1 to 11-13-15-

12-14-16-20 17-19

Footwork 1-3-5-7-9-12-16-20

2-4-6-8-10-14-18

11-13-15-17-19

Abdominals 2-6-10-13

1-3-5-7-9-12-16-20

4-8-11-14

Hip Work 11-13 1 to 5-7-9 6-10-12

Spinal Articula-tion

16 11-13-15-17-19

12-14-18-20

Stretching 1-3-5-7-9-11-13-15-17-19

2-4-6-8-10-12-14-16-18-20

FBI 10-13 14-16 17-19

Arm Work 1-3-5-7-9-12-16-20

2-4-6-8-10-14-18

11-13-15-17-19

Leg Work 1-3-5-7-9-12-16-20

2-4-6-8-10-14-18

11-13-15-17-19

Lateral Flexion 2-4-6-8-10-14-18

1-3-5-7-9-12-16-20

17-19 11-13-15

Back Extension 2-6-10-13

1-3-5-7-9-12 11-13-15 16-18 19 17-20

Resting

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Warm Up includes Standing Roll Down, Pelvic Tilt, Pelvic Curl, Chest Lift, Chest Lift with Rotation, Supine Spine Twist, Changes, and Roll-Up

Footwork includes positions of “heels”, “toes/metatarsals”, “small v”, “wide heels”, “wide toes/metatarsals”, “calf raises” and “prancing”.

Abdominals:

Mat: Double Leg Stretch, Single Leg Stretch, Criss Cross, Hamstring Pu" 1, 100’s

Reformer: 100’s Prep, 100’s , Coordination, Seated Short Box Series

Chair: Standing Pike, ReversePike, Kneeling Pike, Seated Pike

Hip Work:

Reformer Set-Up: Feet-in-Straps (1 red/1 blue spring)

Exercises: Hip flexion and extension, Frog-Press, Openings, Down Circles, Up Circles

Cadi"ac Set-Up: Feet-in-Straps (lying supine/yellow leg springs)

Exercises: Frog-Press, Down Circles, Up Circles

Mat Supine single leg circles: internal and external rotations (r,l)

Spinal Articulation:

Mat Roll Overs

Reformer Supine Bridging Feet on Footbar, Short Spine

Cadi"ac Tower Prep and Tower

Stretching:

Reformer Standing Lunge

Ladder Barrel Standing Single Leg (Hamstring, Quad, Glute, Adductor, and Shoulder Stretch)

Chair Seated side stretch

Full Body Integration:

Mat Plank

Refortmer Hamstring Stretch 1&2, Long Stretch

Cadi"ac Breathing

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Arm Work:

Reformer Seated Chest Expansion, Rhomboids, Hug-a-Tree, High Salute, Kneeling Biceps

Cadi"ac Hug-a-Tree, Bicep Curl

Chair Seated Tricep Press on box or block

Leg Work:

Reformer Single leg Skate, Double Leg Skate, Standing Adductor Press, Hamstring Curl

Cadi"ac Side Lying Leg Series

Chair Mountain Climber

Lateral Flexion:

Reformer Side Over on Short Box, Mermaid

Chair Side Stretch

Back Extension:

Mat Basic Back Extension

Reformer Pulling Straps, Breaststroke

Cadi"ac Prone 1

CONCLUSIONMovement patterns become ingrained in people’s bodies based on their life history, specific incidents, injuries that have occurred, and habitual behavior of daily life. The body will find ways to get the task at hand performed by compensating however it can, usually exploiting strengths to make up for the weaknesses. Imbalances increase if left un-checked over time. In the case of Steve, there were patterns developed early in life to avoid medial knee pain from injuries sustained through skiing. Activities like cycling were performed at proficient

levels by using the bigger superficial muscles such as quads and hip rotators and less intrinsic postural muscles of the spine and core. This repetitive behavior combined with postural

deviations like pronation, externally rotated hips, an anterior tilting pelvis, and kyphosis in the thoracic spine were problematic enough. Combined with the negative effects of sitting

due to his occupation these behaviors probably all contributed in low back/hip pain.

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The BASI block system systematically helped achieve our rebalancing pain reducing goals in some of the following ways:

Goal 1) improve pelvic lumbar stability-Solution: Abdominal Work and stabilizing the pelvis in neutral doing Solution: Hipwork in neutral pelvis...

Goal 2) improve intervertebral articulation through the thoracic spine-Solution: Spinal Articulation Exercises

Goal 3) increase lateral flexion and encourage opening, and pain-free movement in lateral flexion while de-compressing the area around the external oblique and Q.L. attachments at

the illial crest-Solution: Lateral Flexion Exercises and Stretches Goal 4) improve the ability to lift and extend out of a posterior pelvic tilt when seated

without hands- Solution: Footwork on the Wundachair in a seated neutral position-Goal 5) increase hip adductor strength and loosen external rotators of the hip-Solution:

Footwork on the Reformer, Hipwork on Reformer and Cadillac Goal 6) strengthen muscles of the lower extremities and feet in order to eliminate prona-tion and hold a more neutral stance in the ankles and feet-Solution: Footwork on the Reformer Through the work of Pilates, specifically through the BASI Block System we were able to identify Steve’s imbalances and begin to retrain his muscle memory in a more

even, desirable way getting him out of pain and back into a balanced body.

BIBLIOGRAPHY“Persistent back pain and sciatica in the United States: patient characteristics.”Long DM1, BenDebba M, Torgerson WS, Boyd RJ, Dawson EG, Hardy RW, Robertson JT, Sypert GW, Watts C.Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA, Web 2006

"Sciatica" All material adapted used from Wikipedia is available under the terms of the Creative Commons Attribution-ShareAlike License. Wikipedia® itself is a registered trademark of the Wikimedia Foundation, Inc.Web Feb 1, 2011.

“Back Pain, Hip Pain, and Sciatica” by Paul Ingraham, Vancouver, Canada Web, 2012.

“My knee hurts from running!”Jessica LeggioPosted on My Knee Hurts, Running Web May 30, 2013

+++All Images used in this presentation are stock public domain photos.

JESSICA MARIE ROSE

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