Some tools every Pilates Practitioner KNEEDS
We can predict on average that up to 20 per cent of our clientele may present to us with a knee injury* and it is absolutely delightful that we can predict a great success rate in prevention and healing with our Pilates repertoire.
A little chat about the basics of the knee joint to refresh our memories.
The knee is our largest joint and is the most commonly injured. There are bones, cartilage, ligaments and tendons that all work cohesively together and generate our functional knee bend that enables us to walk, squat and stay balanced on one leg. The femur, tibia and patella meet together and form the knee joint. We have a fabulous makeup of cartilage that covers the head of the femur, tibia and the back of the patella. This cartilage enables the knee joint to glide smoothly. There is then a thicker, rubbery wedge shaped substance, a little like a piece of calamari, called the meniscus. The meniscus is between the tibia and femur. The meniscus cushions the joints and acts as a shock absorber between the femur and tibia bones.
The four ligaments of the knee are your, Medial Collateral ligament on the inside of the knee; Cruciate Ligaments, that form an X front and back (anterior and posterior); Lateral Cruciate Ligament. The acronyms being MCL, ACL, PCL, LCL.
The knee is mostly your typical hinge joint range of motion but remember it has 0 degrees of extension (this does not include the hyper extension population around 30 per cent of people) and a range of 135-155 degrees in flexion.
The injury terms you will most commonly hear mentioned are ACL and Meniscus tears. There is also other knee injuries e.g. Bursitis, arthritis and tendinitis and more and less common for e.g. Ilio-Psoas Complex Syndrome (IPCS).
It is important we acknowledge that the clients should seek medical advice if they have had a trauma impact injury and or have intense pain or swelling. Rest, Ice, Compression, and Elevation (also known as RICE) will apply as the very first steps and they may require further imaging.
As Pilates Practitioners you would appreciate the importance of considering the body wholistically and not only at origin of pain or injury. The connective tissue related to the knee and the linking of everything from Cervical alignment to ankle mobility is an entire book of information, therefore I will focus on seven main areas that have established excellent results and are extremely beneficial in the studio practice for Knee injury prevention and rehab.
1. Foot and Ankle Mobility and strength and alignment
2. The Power House (Core, abdominal and lower back and diaphragm), stretch, mobility and strength in a lengthened position.
3. Hip Flexors, Psoas flexibility and strengthen in a lengthened position.
4. Gluteal, flexibility and ensure Quadratus Femoris is working (including hip mobility)
5. Hamstring flexibility and strength
6. Quadricep strength and flexibility
7. Illiotibial Band (ITB) and lateral flexibility
1. Foot and ankle mobility, stability and strength
The Tibia connects to the knee and ankle so it is very important and anatomically obvious that this is pertinent to ensuring ideal Knee function.
If your feet aren’t malleable, they aren’t great shock absorbers and therefore your ankle and knee have to pick up the extra work load. To assist in improving foot mobility and improve weighted distribution here are a couple of simple favourites. The spikey ball for massaging the feet, the foot corrector, for improving the intrinsic foot muscle strength, the toe separator when doing squats to assist in improving alignment through the metatarsals. Prancing (slow and extended stretch) on the reformer and or the bottom loaded tower bar on the trap table.
Massages of the calf muscles by kneeling with the skinny roller behind the knees is excellent for this.
2. The Power House
Stretching through the abdominal - core region is extremely beneficial for knee complaint. If there is tightness through either the anterior or posterior sling system it effects the position of one’s pelvis. This adapted posture could possibly cause an exaggerated posterior/anterior tilted pelvis, translating further down the chain and in turn altering the knee positioning causing unnecessary stress to the knee joint.
The OOV is a tool that surpasses every other two-dimensional small apparatus as it will assist in diaphragmatic breathing, stretching of the abdominal line and the lumbar fascia at the same time. Supine breathing and arm arcs are a priority in assisting to find the ideal body alignment. Using the OOV in its varied positions is fabulous, for example the option of sitting on the neck end and using the belly of the OOV to assist a roll up and supported thoracic extension will also create a clean open line for both the anterior and posterior fascia.
Diaphragm release on the chi balls, or chest lifts over the chi ball.
Barrel back to forward bend, Supine stretch on the spine corrector. All these supported extension exercises can assist with stretching through the abdominals and lumbar tissue.
3. Hip flexor flexibility and strengthening
Hip flexor flexibility and Strengthening in a lengthened position is vital for optimum knee alignment. Consider the attachments of the Psoas major. It originates from the transverse processes and vertebral bodies of T12 – L5 moving inferiorly and laterally running deep to the inguinal ligament and attaching to the lesser trochanter of the femur. Being aware of this and the relationship of the femur and the patella, and the importance of posture it is abundantly clear how important this is for knee rehab. You tend to see this syndrome more in people who are sitting for prolonged periods of time. A dysfunctional hip flexor may lead to faulty biomechanics and this in turn affects the posture and as mentioned with the Power House above, can lead to incorrect loading of the knee joint.
Releasing the Psoas with a chi ball lying prone is a great starting point. Bent knee openings, lying supine with feet on a box and sliding the leg under allowing the leg to relax into eternal rotation at the hip and hold for about 30 seconds. Bridging with feet on a box and have a towel creating a supportive hammock under their hips to assist in creating length of lumbar and space for hip flexors to stretch. You can also utilise a chi ball between knees to assist with correct bony alignment. Supine leg series on the spine corrector is great for lengthening the psoas as well as strengthening. Any of the inverted positions e.g. bicycle/scissors can be wonderful as there is no pressure on the knee.
4. Gluteal Stretch and strength
Your gluteus maximus supports your pelvis, if it is weak it can cause a change in the pelvis position. A drop of the pelvis may cause the knee alignment to roll in where as the Gluteus medius weakness may cause knee valgus (when the bone at the knee joint is angled out and away from the midline). Then the quadratus femoris muscle even though small, plays many important roles in stabilising the hip joint by keeping the head of the femur in place and it also produces external rotation of the thigh in the hip joint when the leg is in anatomical position. The Quadratus Femoris (QF) originates on the ischial tuberosity and attaches to the femur so again the relationship to the knee joint is very clear from its attachment. If there is a weakness or tightness over riding one or the other your entire relationship to the knee joint is compromised.
Stretching the glutes in a pigeon pose type position is great if the client is not acute as the angle of the knee can be problematic. Creating massage release for the gluteal without strong angles of the knee are very effective. E.g. Rolling out the glutes on the roller or spikey balls is a great way to start.
Strengthening is super important in rehabilitation and of course prevention. The QF does tend to be the overlooked superhero I feel in this story. I have noted over the years the excessive reference to Glute med and min strength but little talk about the lower glutes playing an important role. It is a stabiliser of the hip by keeping the head of the femur in place therefore extremely problematic to the knee if it is weak. A favourite of mine to wake up the QF is a one legged balance cross over. Let me explain a little. Standing on one leg with alternate leg bent (like a stalk), raise the arm of the lifted leg to ceiling. Bend standing leg and simultaneously bring the raised hand to touch the little toe of the standing leg. Return to standing stalk pose. Repeat 8-12 times. Add a weight when confidence increases, modify by holding onto a balance pole, barre or wall.
5. Hamstring flexibility and strength.
For Hamstring flexibility and strength you cannot go past feet in straps on the reformer, on the trapeze table and or theraband.
6. Quadricep strength and flexibility.
The importance of the quadricep muscle group is to help straighten your knee but they also absorb the force when your heel hits the ground in your gait and also stabilise the knee by holding the patella inside a groove in the femur. Weakness in this muscle group can change the shock absorption and or recruit poorly from other areas of the body.
I highly recommend seated footwork on the reformer and or the chair as it allows a great visual of the tracking system from hip, knee to ankle and the use of the stopper (on the reformer) means you have many options when rehabbing to ensure the flexion can be controlled. Standing squats from the end of the trap table and standing leg pump are all very important in building confidence and knowledge and of course strength in a controlled range.
Stretching of the quadriceps can often require deep flexion of the knee, I therefore recommend rolling the thighs on the roller lying prone supported on forearms.
7. Iliotibial band and lateral flexibility
The ITB is a thick band of fascia that runs from the fascia of the gluteus maximus, gluteus medius and Tensor fascia Latae (TFL). Its main functions are to stabilise the pelvis and posture control. ITB syndrome can cause pain generally on the outside of the knee and is often felt through exercise and or walking or running. The ITB becomes problematic when it becomes too tight, causing friction at the top of your hip and near the lateral side of the knee.
Foam rolling the ITB assists in increasing tissue flexibility and increases blood flow. All of the Pilates side-lying mat exercises with or without bands, crab walks, side planks and abduction of the top leg are also incredibly beneficial.
It is often assumed you only need to release the ITB, please consider that the rolling allows better blood flow to increase the workload of strength, rolling alone will not be as beneficial.
The complexity of the human body is forever unveiling itself and it is always a privilege to delve deeper and improve our understanding of certain errors of the body, however always remember that although your client may present with a knee complaint the entire body requires your attention.
Kimberley Garlick is a Senior Polestar Practioner and owner of Northern Rivers Pilates in Lismore.
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