Pilates for lower extremity strength
Nadine Lennon September 2018 CTTC Feb 2018 Cape Town
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Abstract
The lower extremity of the body is often mistaken for just the leg… it involves so much more. This part of the body includes hip and thigh, knee and leg, ankle and foot. The alignment of this part of the body is vital for the body as a whole. Muscle imbalances in the hip, for example, can cause problems for the lower and upper back (e.g. Trendelenburg). Incorrect alignment of the feet can cause a ripple effect for the knees that in turn cause issues for the hips etc. Incorrect alignment of the hips can also cause a host of issues, some including genu vagus and varum. Throwing hypermobility into the mix also adds to complications if they go unaddressed. Hypermobility is higher than average flexibility in one’s joints that those of others. This can be cause by genetics, overuse or injury in that particular area.
My case study has provided me with the opportunity to research this topic in depth. What started out as a knee issue and rehabilitation, has led to the discovery that in fact there is misalignment throughout the lower extremity. Focusing and queuing the client correctly can lead to better adjustment, awareness and alignment. We will focus on the feet and working on the pronation, the knee area to strengthen the muscles around this joint and bring awareness to the hypermobility, thus creating more stability. Finally, we focus on the hip girdle and specifically the strengthening of the gluteal muscles.
Given that Pilates is in fact a mind and body connection, my client has also felt better emotionally and psychologically from seeing improvements and strength in her body over the course of our interaction. She has suffered from depression especially after her last injury as it prevented her from continuing life as a normal, then 18-year-old female.
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Table of Contents
1) Diagrams of the Lower extremity – a) Muscles…………………………………………………………………………
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b) Bones …………………………………………………………………………..
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2) Introduction a) Importance of the lower extremity…………………..………….
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b) Major Players……………………………………..………………….……..
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c) Function of each major Player…………..………………..…………
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3) Case Study………………………………………………………………………..
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4) Conclusion…………………………………………………………………………..
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5) Bibliography…………………………………………………………………………
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6) APPENDIX - Program…………………………………………………………… 13-18
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Muscles of the Lower extremity
Bones of the Lower extremity
Diagram 1
Diagram 2
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Incorrect foot & hip alignment Muscles of the hip – anterior and posterior
Diagram 3
Knee Joint
Diagram 4
Diagram 5
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Introduction 1) Importance of lower extremity
Importance of lower extremity is quite simple in that it SUPPORTS the entire body’s weight during all movement – jumping, walking, running, dancing and even standing stationary. There are also multiple and complex muscular attachments. Just look at Diagram 1 to see how complex the structure is, and this isn’t even looking at bones and nerves. This is clearly seen from the start of the gait cycle when pushing off the foot, the sequence of events follows from there to the extension of the hip to the pelvis upward through to the spinal extensors. Therefore, lets break down the major players of this area and their specific functions. We can then look at how our BASI block system can create specific exercises to aid in our goals to strengthen and find alignment, ease and stability due to hypermobility and some pronation awareness. 2) Main PLAYERS of lower extremity - Hip - Thigh - knee - Leg - Foot 3) Functions of each PLAYER - FEET I decided after the first 4 of sessions that I would concentrate on the feet first for the next 34 classes having noticed the extent of the pronation and ankle discomfort after footwork on the Cadillac. “The feet have a direct influence on movement since anything that affects the highly innervated soles of the feet can find swift response in the whole body” – Madeline Black. Just ask any parent who has happened to step on mislaid lego bricks. One will be hard pressed to find a form of healthy movement that concentrates on the feet as much as we do in Pilates – whether it is the pedal of the chair, the footbar, jump board or straps of the reformer, or
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the tower bar of the Cadillac or the mat where you are on your feet for multiple exercises – Pilates works the feet in a manner you will not find elsewhere. -
LEGS/THIGHS
As seen in diagram 2, the tibia bone in the lower leg is involved in both knee and ankle joints and its a strong weight bearing bone, whereas the fibula is a thinner bone, also the longest in the body, acts an attachment for muscles. Attached is the soleus and gastrocnemius muscles that allow for plantar flexion of the foot. The femur is the largest and heaviest bone in the body and is a major player for both the hip and knee joints. In this upper section of the leg you have major muscle groups a) hamstrings x3 muscles (back of thigh allowing the knee flexion), b) quadriceps x 4 muscles (front of the thigh allowing knee extension) and then c) the adductors x 5 muscle ( inside of the thigh allowing the legs to come together). As seen in diagram 1. These are just the focus points in this paper, this not an exhaustive list.
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KNEE
The knee is a shock absorber of the body as the foot moves and pushes off in gait. Its allows the leg to flex and extend and connects the lower leg to the upper leg. Patella – protects the knee joint and primarily supports extension of the knee and allows for smooth movement of knee flexion. Dislocation of the patella, as in the case of my client, is quite common especially among young female athletes.
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Hip
The hip is a very important junction of our bodies. It connects the lower and upper part of the body together. Its main function is to support the body weight when moving or stationary. It is an important player for balance and any injuries to the hips can have huge ripple effects across the whole body. The major muscle groups here include the flexor muscles, the extensors, the
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abductors, the adductors, and finally the internal and external rotator muscles. The hip is a very complex area and involves many nerves and ligaments too. These main players have a profound affect on the rest of the body and any issues from the feet up to the hips can case such wave effects that it can initiate pain and misalignment into the spine and upper body.
Case Study
Cassidy is a 19 year old former dancer who has unfortunately been plagued with various injuries. 2011 – fractured a bone on the left side of her left foot 2014/2015 – diagnosed with Severs disease, plantar fasciitis and the beginning of shin splints 2016 – tore a ligament near the ankle on the left side of left foot 2017 – deeply bruised the left side of left foot as well as sacrum and coccyx. 2018 – dislocated left patella Cassidy has been to physio for some time and her mom, a friend of mine suggested she come to see me as she would be a great case study. I started with an assessment. However, it was rather difficult to assess this client at first due to her high-level knowledge of her own body given her history. She walked into her first meeting with me with unbelievable control of her body. Knowing what she needs to work on from her long-term physio work, she kept it all together. It took a couple of classes and challenges for her to finally let go holding herself together so well, for me to really see what is going on.
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From this point I was able to assess 1. Hyper extension of both arms and legs 2. Slight sway back posture 3. Pronation of feet but more pronounced in left foot. Objective
1) To rehab the knee – strengthening the muscles around the knee joint 2) To address the pronation – focus on the calf muscles, hip abductors and adductors and the posterior tibialis and peroneus longus. 3) To focus on the hip – by strengthening the gluteals Since meeting Cassidy, it has kept me wondering why her left side continues to get injured so much more than the right. The pronation of the left foot would be the start of my focus. And so, the plan would grow from here to use the BASI block system to strengthen the overall body with focus on the areas of our objective. Continual reinforcement to correctly align the hips, knees and feet in conjunction with constant queuing to activate her quadriceps. These areas are my focus when it comes to queuing my client – for example “pulling up from the knee caps”, “reaching long and out of the hip socket”,” reaching your foot toward the mirror opposite”, “place your ribs into the carriage” and “reach pubic bone to nose” are some of the phrases I would use. etc. As my client is also hypermobile I do have to cue “soft bend in the elbows and knees” to prevent locking into those joints causing extra strain. Specific Pilates exercises - see appendix for Weeks 1-8
My client must work on strengthening her gluteals, quadriceps, hamstrings and VMO. Thus far we continue using the BASI block system to help strengthen these areas. Footwork is a great way to get an overall workout with regards to the areas we are targeting. Apart from the Open Heels on the Cadillac where my Clients left foot was not in a happy place and the Open Toe on the Chair where the 9
left foot showed some considerable weakness, the rest has been working very well and we can see that she gains strength each week. The hip work is an excellent place to ensure that she maintains trunk stabilisation and adding some single leg hip work is great for ensuring that both legs are working equally.
The side lying leg series is fantastic for really connecting the body and mind together to bring awareness to the gluteal area, it targets the abductors and combines knee flexion and extension without added body weight. This area being weak, we are going to continue to incorporate this specific repertoire weekly as the benefits will be more visible. In some cases, during the repertoire I have used footwork in isometric contractions to assist in engaging the required muscles for stabilization. The hip work has been excellent for strengthening the adductors, hamstrings and hip flexors. We also incorporate bridging in the form of pelvic curls (with some variation) and bottom lift after week 10 for the glutes, hamstrings and to stabilise the back of the knees. We have avoided areas where my client has had to work on her knees. We attempted to give kneeling lunge a try in Week 4 but despite the knee pad, my client did not feel comfortable on the patella. In addition, we also did plenty of toe/foot exercises to aid in strengthening the arch of the foot and release fascia under the foot. I have also added props as an assist, such as the foam roller, the TheraBand, magic circle and the ball to further aid in reaching our goals.
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Conclusion
I can conclude that while this will be an ongoing journey for both my client and I, there has been remarkable progress made since we started our journey together. There is more strength in the muscles that she now uses when going about her daily life – driving and hiking. Being conscious to walk correctly to engage her glutes, foot placement and knee alignment. Therefore, it is essential to continue working in strengthening these areas as we can see from the conclusion from a study conducted and published in the Journal of Athletic Training; “When considering the potential relationship between lower extremity alignment and lower extremity injuries, we cannot ignore the fact that subtalar joint pronation is the lower extremity alignment variable most commonly linked to lower extremity injuries.” - Anh-Dung Nguyen et al.
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Bibliography
1. Physical Assessment for the Pilates Professional by Physical Therapy of Los Gatos – Ariel LeHaitre, MSPT Rob Naber, PT, OCS, A.T., C. Jenny Warner, DPT 2. Diagram from www.anatomyofscience.com 3. Centred – Madeline Black 2017, Handspring Publishing Limited 4. www.corewalking.com 5. www.kenhub.com 6. BASI comprehensive Study Guide 7. Journal of Athletic Training “Identifying Relationships Among Lower Extremity Alignment Characteristics by Anh-Dung Nguyen, PhD ATC and Sandra J. Shultz, PhD ATC CSCS, 2009 National Athletic Trainers Association 8. BASI Comprehensive Study Guide, Rael Isacowitz, Costa Mesa 2000-2013 9. BASI Reformer Movement Analysis Workbook, Rael Isacowitz, Costa Mesa 2000-2013 10. BASI Cadillac Movement Analysis Workbook, Rael Isacowitz, Costa Mesa 2000-2013 11. BASI Wunda Chair Movement Analysis Workbook, Rael Isacowitz, Costa Mesa 2000-2013 12. BASI Auxiliary Movement Analysis Workbook, Rael Isacowitz, Costa Mesa 2000-2013 13. BASI Mat Movement Analysis Workbook, Rael Isacowitz, Costa Mesa 2000-2013
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Appendix
BASI Block System WARM UPs
FOOTWORK
ABDOMINALS
HIP WORK
Exercises Week 2
Exercises Week 1
Exercises Week 4
Exercises Week 3
Roll downs Pelvic Curls Spine Twist Supine with Foam Roller Chest lift (+ rotation) Roll Ups
Roll downs Pelvic Curls Spine Twist Supine Chest lift (+ rotation) Roll Ups
Roll downs Pelvic Curls Spine Twist Supine Chest lift (+ rotation) Roll Ups
Roll downs Pelvic Curls Spine Twist Supine with Foam Roller Chest lift (+ rotation) Roll Ups
Parallel heels Parallel Toes V Toes Open Heel Open Toes
Parallel heels Calf Raises Parallel Toes Prances Single Leg Heel V Toes Single Leg Toes
Parallel heels Parallel Toes V Toes Open Heel* Open Toes
Hundred Prep Co-ordination
Hundred Prep Co-ordination
Warm Up series
Frog Circles down Circles Up Openings
Frog Circles down Circles Up Openings
Frog Circles down Circles Up Openings
Frog Circles down Circles Up Openings
Shoulder Stretch 1 Gluteals Hamstrings Adductors Hip Flexors
Gluteals Hamstrings Adductors Hip Flexors
Kneeling Lunge***
Calf Raises Prances Single Leg Heel Single Leg Toes
Calf Raises Prances Single Leg Heel Single Leg Toes
Parallel heels Parallel Toes V Toes Open Heel Open Toes
Calf Raises Prances Single Leg Heel Single Leg Toes**
Standing Pike Standing Pike Reverse
SPINAL ART
STRETCHES
Standing Lunge
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BASI Block System
Exercises Week 2
Exercises Week 1
Exercises Week 4
Exercises Week 3
FULL BODY I
Up Stretch 1 Elephant
Up stretch 1 Elephant
ARMS
Supine Arm Series
Sitting Series
Side Spilts
Up stretch 1 Elephant
Scooter
Standing Series
Side lying series
Single Leg Skating
Supine Arm Series
FULL BODY II
LEGS
Lateral rotation/Flexion
Back Extension
Side lying series
Mermaid
Mermaid
Side Over
Side Over
Pulling Straps 1
Pulling Straps 1
Breaststroke Prep
Swan Basic
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BASI Block System WARM UPs
FOOTWORK
ABDOMINALS
HIP WORK
Exercises Week 8
Exercises Week 7
Roll downs Roll Ups Spine Twist Supine Double Leg Stretch Single Leg Stretch Criss Cross
Parallel heels Calf Raises Parallel Toes Single Leg Heel Single Leg Toes** V Toes Open Heel Open Toes
Roll downs Warm up Series
Roll downs Pelvic Curls Spine Twist Supine Chest lift (+ rotation) Roll Ups
Roll downs Roll Ups Spine Twist Supine Double Leg Stretch Single Leg Stretch Criss Cross
Parallel heels Calf Raises Parallel Toes Single Leg Heel V Toes Single Leg Toes Open Heel Open Toes
Parallel heels Calf Raises Parallel Toes Prances Single Leg Heel V Toes Single Leg Toes
Parallel heels Parallel Toes V Toes Open Heel* Open Toes
Bottom lift with RUB
Hundreds 1/2 Co-ordination
Breathing with Push Through bar
Frog Walking Circles down Bicycle Circles Up Reverse Bicycle Openings
Frog Circles down Circles Up Openings
Frog Circles down Circles Up Openings
Single Leg side Series
Bottom Lift
Short Spine
Monkey Original
Standing Lunge
Gluteals Hamstrings Adductors Hip Flexors
Standing Lunge
SPINAL ART
STRETCHES
Exercises Week 6
Exercises Week 5
Gluteals Hamstrings Adductors Hip Flexors
Calf Raises Prances Single Leg Heel Single Leg Toes
Standing Pike Standing Pike Reverse
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BASI Block System
Exercises Week 6
Exercises Week 5
FULL BODY I
Up Stretch 1 Elephant
ARMS
Shurgs Tricep Press
Scooter
Exercises Week 8
Exercises Week 7
Siting Forward Side Reach
Supine Arm Series
Sitting Series
Side lying series
Single Leg Skating
Stomach massage Series
Standing Series
Side lying series
FULL BODY II
LEGS
Lateral rotation/Flexion
Back Extension
Backward step down**
Side over prep
Mermaid
Side Over
Side Over Prep
Swan Basic
Pulling Straps 1
Breaststroke Prep
Swan Prep
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Equipment Key Ladder Barrel
MAT
Notes • Client did not feel happy with her feet in Open Heel position. This is when my focus shifted from knee rehab to lower extremity as a whole. ** Clients left foot struggled with this *** Client’s left knee did not feel comfortable despite knee pad
Reformer
Chair
Cadillac
Step Barrel
In addition to the BASI Block system, I also incorporated:A. Theraband stretching and exercises to engage the gluteals. B. Small ball exercises for under the feet for fascia release and arch awareness. C. Foam Roller D. Ball – specifically to engage inner thighs and VMO activation
Auxiliary 17
